Community Care Services Eligibility Handbook

2100, Case Management

2110 Description of Case Management

Revision 24-3; Effective July 1, 2024

26 Texas Administrative Code Section 271.79 says people must meet the eligibility criteria for CCSE services and can receive case management without receiving services. Ineligible applicants receiving only information and referral are not eligible for case management.

Case management is a set of actions taken by a Texas Health and Human Services Commission (HHSC) caseworker to determine:

  • if a person requesting service is eligible for HHSC services;
  • what services the person needs; and
  • who will provide those services.

Case management also includes:

  • referring eligibles to service providers and facilitating the referral;
  • monitoring the referral to ensure that the services are initiated;
  • monitoring the service provision to ensure that services are meeting the person's needs; and
  • periodically reassessing the person's financial and functional eligibility.

2120 Case Management Process

Revision 24-3; Effective July 1, 2024

Case management involves six single functions.

  1. Intake — Requests for service or information are made by the person or someone on the person's behalf by phone, letter, or in-person. Texas Health and Human Services Commission (HHSC) intake staff:
    • determine the precise request;
    • record certain information from the requester;
    • give the requester certain information;
    • determine if an immediate, expedited, or routine response is necessary; and
    • refer the request to the appropriate unit for further action.
      Review 2200, Intake Procedures for detailed intake procedures.
  2. Assessment — HHSC caseworkers respond to intake by visiting the person at home or in another setting to assess eligibility and needs. The assessment process includes:
    • determining financial eligibility;
    • determining functional eligibility for the performance of activities of daily living;
    • assessing the person's home, social, and environmental supports, and resources;
    • determining services the person needs and if family or community resources are currently meeting those needs; and
    • assessing the person's physical condition and determining if that condition and their environment pose any risk.
      Review 2400, Assessment Process for detailed assessment procedures.
  3. Service planning — Caseworkers develop a service plan with each eligible person after completing the assessment. Service planning includes:
    • determining what services and environmental adaptations are required to satisfy the person's personal unmet needs, health, and safety;
    • determining and specifying what services will be secured from whom or from where, how much will be provided, and on what schedule;
    • specifying how often the caseworker will monitor the provision of services and personal satisfaction; and
    • getting the person's agreement with the service plan.
      Review 2500, Service Planning for detailed service planning procedures.
  4. Service authorization
    1. Non-Medicaid services — If non-Medicaid HHSC services need purchasing as part of the service plan, the caseworker:
      • authorizes the services per program policies and procedures;
      • sends the service plan and person’s referral information to the provider selected by the person; and
      • discusses the plan with the potential provider, as necessary.
    2. Medicaid services — If Medicaid services need purchasing as part of the service plan, the caseworker:
      • designates the services per Medicaid program policies and procedures;
      • if necessary, gets consultation from the regional nurse about medical need for services;
      • sends the service plan and person’s referral information to the provider selected by the person;
      • discusses the plan with the provider supervisor, if requested; and
      • discusses the plan with the regional nurse, as necessary.
        Review 2600, Authorizing and Reassessing Services for detailed service authorization procedures.
  5. Service monitoring and evaluation — The caseworker:
    • contacts each person after service referral, per case management requirements, to ensure that services were initiated as scheduled and to determine the person's satisfaction with the service;
    • contacts and visits each person per the individualized case management plan or upon request by the person or others;
    • accompanies regional nurses on utilization review home visits when requested;
    • evaluates the person's condition, needs, and service provision on an ongoing basis, per HHSC procedures and individual requirements;
    • requests consultation and joint home visits with the regional nurse, provider nurse, or both when indicated because of the person's health condition or risk status;
    • receives information from providers about the person's ongoing needs and conditions; and
    • reassesses a person's needs and reviews and reauthorizes service plans per required schedules.
      Review 2700, Service Monitoring, Changes, and Transfers, for detailed procedures concerning service monitoring.
  6. The caseworker is also responsible for helping people who have lost their Your Texas Benefits (YTB) Medicaid card or never received it. Review 2130, Your Texas Benefits Medicaid Card and Replacement, for detailed procedures.

2130 Your Texas Benefits Medicaid Card and Replacement

Revision 24-5; Effective Nov. 1, 2024

Form H3087, Medicaid Identification, is no longer issued and was replaced by the Your Texas Benefits (YTB) Medicaid card.

The YTB Medicaid card is a plastic card. Providers must verify eligibility before providing services, as the card does not prove ongoing Medicaid eligibility. Medicaid recipients must take the card to doctor or dental appointments and the pharmacy. This card is for permanent use, and the Texas Health and Human Services Commission (HHSC) only issues a new card if it is lost or if the information printed on it changes.

The person may call 855-827-3748 if the card is lost and they need a replacement card. Medicaid providers and pharmacies can verify eligibility by phone using a provider-dedicated line. So, even if a card is lost, the Medicaid recipient can receive services or fill a prescription. The card should not be thrown away, even if the recipient is denied Medicaid, since the card will be reused if the person regains eligibility.

Requesting Form H1027-A, Medicaid Eligibility Verification

Form H1027-A, Medicaid Eligibility Verification, is a secure form. It is not available on the website and must be ordered. However, the form instructions are available on the Texas Health and Human Services forms webpage to complete the form. Designated HHSC staff may continue to help people in the following situations:

  • Ongoing Medicaid Recipients — HHSC staff may help with a manual Form H1027-A upon request because the recipient lost or did not receive the YTB Medicaid card. HHSC staff issuing Form H1027-A should inform the recipient of the following:
    • Call 855-827-3748 for a replacement card.
    • The burden of verifying Medicaid eligibility is with the provider.
    • A person who is Medicaid eligible, but does not have written proof of eligibility, should still be able to get services from their provider or to fill a prescription.
    • Medicaid providers and pharmacies can verify eligibility by phone using a provider-dedicated line or the Texas Medicaid & Healthcare Partnership (TMHP) TexMedConnect website.
  • New Medicaid Recipients — Eligibility information is not immediately available for providers or pharmacies to verify after Medicaid is approved. HHSC staff must refer the recipient to the HHSC Benefits office to issue Form H1027-A between the time eligibility is determined and the time eligibility is available in the online system.

Once the recipient receives the replacement card, they present it to the Medicaid provider or pharmacy when services are requested. The recipient may call 800-252-8263 or 2-1-1 to confirm Medicaid coverage if they are not sure of their eligibility status.

More information about the new card is available at www.yourtexasbenefits.com.

2200, Intake Procedures

2210 Requests for Services

Revision 24-5; Effective Nov. 1, 2024

A request for services may begin with

  • phone or written referrals from other agencies, organizations, and HHSC divisions; or
  • phone, written, or walk-in requests from people or their relatives, friends, or other interested people.

2211 Applications and Referrals Routed from the Austin Document Processing Center

Revision 24-3; Effective July 1, 2024

When the Austin Document Processing Center (DPC) receives an application requesting a Community Care Services Eligibility (CCSE) referral, the DPC will fax the first three pages of the application and a cover sheet to the CCSE local office. CCSE staff reviews each of the referrals and contacts the person to determine if the person is interested in CCSE services. They then take the following actions:

If it is determined the person is interested in a CCSE program without an interest list, CCSE staff:

  • Completes an intake for the services requested and accesses the HHSC Benefits Portal.
  • Prints out the rest of the application.
  • Clicks on the PT Inquiry tab and opens the PT inquiry.
  • Clicks on Inbound Correspondence Image Repository Search and searches for the person.
  • Selects the appropriate document and clicks view.
  • When the PDF document opens, click on the printing icon to print the document.

If the person is only interested in a program with an interest list, the person will be placed on the interest list, and staff will not need to print the remainder of the application.

If the person is not interested in a CCSE program or a program with an interest list, file the fax from DPC following local office procedures.

The document processing center address is:
Document Processing Center
P.O. Box 149024
Austin, TX 78714-9024
Fax Number: 877-236-4123

2220 Response to Requests for Service

Revision 18-1; Effective June 15, 2018

When a request for service is received by telephone, written referral or in person, the HHSC staff who conducts intake for community care services or who receives a request for service gives the requester information about HHSC CCSE services and determines what service is being requested and whether HHSC provides that service.

Upon receipt of a written/faxed referral, the applicant or responsible party may be contacted by intake staff or the referral may be accepted, entered in the Intake (NTK) system and assigned to a case worker. The case worker would then make the initial contact, provide information about HHSC and screen for appropriate services.

The intake staff or case worker who conducts intake for community care services or who receives a request for service:

  • gives the requester information about HHSC, including CCSE services, as needed;
  • determines what service is being requested and whether HHSC provides that service;
  • refers the request for non-HHSC services to the appropriate state or community agency and documents the request;
  • refers individuals who are currently in nursing facilities and still require skilled services, but would like to return to the community, to STAR+PLUS Home and Community Based Services (HCBS);
  • screens all applicants indicating a need for skilled services for a nursing facility diversion (NFD) slot placement when slots are available and completes the NFD tab in NTK if the applicant responds there is a chance he would have to move to a facility. If slots are not available, refer the individual to the STAR+PLUS HCBS interest list;
  • transfers to appropriate staff any requests for HHSC services other than community care services;
  • identifies reports of suspected need for Adult Protective Services (APS) and immediately provides these reports to APS staff;
  • obtains eligibility-related financial information about the applicant; and
  • gives the requester general information about CCSE eligibility, emphasizing that exact eligibility information cannot be given until the individual is interviewed by a case worker.

If the requester does not want to apply for CCSE services, the requester is transferred to appropriate staff for requests for HHSC services other than community care services or referred to other appropriate resources. See Appendix XV, Services Available from Other State Agencies, and 2530, Other Resource Services. The information is not entered into NTK and an intake is not completed. This information is recorded in an Information and Referral Log.

If the individual wishes to apply for CCSE services, the intake person:

  • completes the intake by entering the information into the automated system for intakes or completes Form 2110, Community Care Intake, according to the form instructions, completing only the required sections if some information is not available;
  • documents on the form or on a log any requests for information and referral according to regional procedures;
  • refers walk-in requesters to the appropriate unit for the completion of applications;
  • determines whether the requester can and will complete an application for the applicant;
  • identifies a responsible party who will help with the application process;
  • identifies and documents which persons have no relative or responsible person to help with the application process;
  • assesses the urgency of the request and immediately routes all requests to appropriate units for further action (See 2310, Criteria for Immediate or Expedited Responses to Service Requests); and
  • informs the requester that a case worker will contact the applicant to further discuss the application process.

For all individuals who currently do not receive Supplemental Security Income (SSI) or SSI-related Medicaid and are requesting personal attendant services (PAS), the intake screener must assign the intake to a case worker as an application for Community Attendant Services (CAS). Intake screeners must not screen applicants for a specific service or determine if an applicant should only be assigned for Family Care or placed on the interest list for Family Care services. The intake screener does not place the individual on the Family Care interest list. The case worker determines whether the individual will be placed on the interest list, as described below.

All individuals who are not currently receiving Medicaid and wish to apply for PAS must be seen by a case worker and assessed for CAS. During the initial interview, the case worker screens all applicants for potential eligibility for CAS and determines whether or not the applicant will be referred to MEPD for CAS.

Certain services require special intake procedures. For details, see 4000, Specific CCSE Services.

2221 Requests for STAR+PLUS Services

Revision 24-3; Effective July 1, 2024

When the Texas Health and Human Services Commission (HHSC) receives a request for services, staff must assess if the request for services should be forwarded for processing to the:

  • appropriate HHSC STAR+PLUS department; or
  • managed care organization (MCO).

Refer to the charts in the STAR+PLUS Handbook for more information.

People awaiting managed care enrollment may be assessed for interim services from CCSE.

CCSE will enroll people who meet the Primary Home Care (PHC) immediate or expedited criteria, described in 2310, Criteria for Immediate or Expedited Responses to Service Requests, into PHC when they are listed in the Texas Integrated Eligibility Redesign System (TIERS) as a candidate for STAR+PLUS enrollment. However, mandatory STAR+PLUS people who are not yet enrolled with an MCO, and do not meet immediate or expedited criteria, will be referred to the Enrollment Broker. People who are already enrolled with an MCO and request PHC or Day Activity and Health Services (DAHS) from CCSE must be advised to contact their MCO.

CCSE will not enroll people in DAHS when they are listed in TIERS as candidates for STAR+PLUS enrollment. Since there are no immediate or expedited criteria for DAHS enrollment, people seeking these services will be available upon enrollment for the STAR+PLUS program. DAHS facility-initiated referrals that take place for people pending STAR+PLUS enrollment will not be reimbursed by HHSC.

Refer to the STAR+PLUS Handbook, Section 3221, Mandatory Groups, and Section 3222, Excluded Groups for a list of mandatory and non-mandatory STAR+PLUS participants.

2222 Reinstatement Procedures for People Reapplying for Services After Loss of Financial Eligibility

Revision 24-3; Effective July 1, 2024

If a person has lost categorical or financial eligibility, creating a gap in service, the following procedures apply.

If financial or categorical eligibility is re-established within 60 days of the denial date and the person reapplies for services, the caseworker may use the current information on file to determine eligibility. A new Form 2110, Community Care Intake, must be completed. The caseworker must note in the Comments section of Form 2110 that reinstatement procedures are being used within 60 days of the denial date.

Review 3441.2, Reinstatement Procedures After Denial, for complete procedures.

2223 Caregiver Support Assessment Initiative

Revision 24-5; Effective Nov. 1, 2024

Background

Senate Bill (SB) 271, 81st Legislature, Regular Session, 2009, relating to informal caregiver support services, directs Texas Health and Human Services Commission (HHSC) staff to:

  • raise awareness of services available to caregivers;
  • perform outreach functions to informal caregivers; and
  • gather information about the needs of caregivers, including the:
    • collection of profile data on informal caregivers;
    • referral provided to support services, when appropriate; and
    • implementation of a standardized caregiver assessment tool to evaluate the needs of caregivers.

SB 271 requires HHSC to use the information collected to refer informal caregivers to available support services and to:

  • evaluate the needs of assessed informal caregivers;
  • measure the effectiveness of certain informal caregiver support interventions;
  • improve existing programs;
  • develop new services, as necessary, to sustain informal caregivers; and
  • determine the effect of informal caregiving on employment and employers.

The Caregiver Status Questionnaire (CSQ) is designed to meet the requirements of SB 271. The information collected is analyzed and included in the HHSC report to the governor and the Legislative Budget Board. HHSC is required to submit this report in December of each even-numbered year, beginning Dec. 1, 2012.

Completion of the CSQ

The CSQ is available in the Long-Term-Care Services Intake (NTK) System. When possible, it is completed at the time of the intake contact. The CSQ and a script for the interview are available in English and Spanish in Appendix XXXVIII, Caregiver Support Assessment Initiative. If not feasible, one more contact with the caregiver must be attempted within five business days. If it is necessary to go beyond the five-business-day period, document the reason in the comments section of the CSQ. When a follow-up contact is made, enter the date in the top right corner of the CSQ, just under the NTK menu bar. Check the appropriate box to show if the attempt to contact failed or the caregiver declined to participate.

Staff should always assume there is no assessment and proceed as usual. If the caller states they have completed the caregiver assessment in the past, staff should not ask them to complete the assessment again. Staff may exit the caregiver screen by selecting yes at the top of the page to the question: Caregiver declined to answer?. In the comments section at the bottom of the page, document that an assessment has already been conducted for that caregiver.

The purpose of the CSQ is to collect the information described above. This information is not used to determine if the unmet need criteria for Community Care Services has been met and will not be forwarded to the caseworker.

Question Sensitivity

Some staff may find asking some of the questions on the CSQ is awkward. While understandable, all the questions must be asked, and a response recorded. It is not acceptable to skip a question. If a person seems resistant to answering any of the questions, do not insist on a response. Document the person’s refusal to answer and continue to the next question.

Caregiver Employment

Checkboxes are provided to record how caregiving responsibilities affected the caregiver's employment. After asking the open-ended question, listen to the caregiver's comments and check all the applicable boxes. You are not expected to read aloud each possible response to the employment question. However, the list can be used as a prompt if the responder is unsure how to answer aloud. If the person seems uncertain, you may read the response category headings. Example:  Has caregiving affected your employment schedule, pay, leave, performance or work relationships?  If further clarification is necessary, you may ask the question differently. Example: Have you had to take extra leave or change your work schedule to meet your caregiver responsibilities?

Referral to the Area Agency on Aging (AAA)

If the person meets one of the following criteria, they may qualify for services from the AAA. If the person would like help, refer per regional procedures.

AAA Eligibility Screening Criteria

The person may qualify for services from AAA if the person is:

  • 60 or older and is caring for a person of any age;
  • 55 or older and is caring for a grandchild under 18 in their home because:
    • the biological or adoptive parents are unable or unwilling;
    • they have legal custody or guardianship or are raising the child informally;
    • they are caring for a person 19-59 living with severe disabilities; or
    • they are a caregiver for a person of any age who has Alzheimer's or dementia.

Accessing the CSQ

Use the manual copy of the CSQ when the automated system is unavailable. However, all information must be entered into the automated system as soon as possible. The version of the CSQ, which includes a script and instructions on recording responses, may be helpful for staff completing the CSQ for the first few times. Follow the instructions below to complete the CSQ.

  1. Conduct intake per usual procedures using the NTK system.
  2. Document if the person requesting services has a caregiver at the Client Information screen. If there is a caregiver, the CSQ must be completed at the end of the intake process if the caregiver is available. If the caregiver is not available, document the caregiver’s contact information. At least one follow-up attempt must be made to contact the caregiver later.
  3. Select the Caregiver tab on the NTK section selection menu.
  4. Enter the information on the Caregiver screens, as requested.
  5. At the end of the CSQ, if the person requesting services may qualify for services from the AAA, make a referral following regional procedures.

The collection of legislatively mandated information enables the state to refer caregivers to available support services and to develop more services to meet caregiver needs.

2230 Interest List Procedures

Revision 24-5; Effective Nov. 1, 2024

People who express interest in a community services program with an interest list are registered on the Community Services Interest List (CSIL), regardless of the program’s enrollment status. CSIL records the date and time of the expressed interest. If the person is first on the list and the region is releasing and enrolling for that program, the person may be immediately released and assigned for the enrollment process.

If no Title XX funds are available, consult with the person to decide if their needs can be met through other services. If the person agrees, add the person’s name to the appropriate interest lists by entering the information in the CSIL system if no other service is available or suitable. People who request placement on an interest list must live in Texas. An out-of-state address can be used as a contact if the power of attorney, guardian or legally authorized representative lives out of state. Additional exceptions may be made for people placed on an interest list while living in Texas, who then move temporarily out of the state because of military assignments.

People on military assignments who are temporarily out of state include:

  • Military member - A member of the United States military serving in the Army, Navy, Air Force, Marine Corps, or Coast Guard on active duty who has declared and maintained Texas as the member's state of legal residence in the manner provided by the applicable military branch;
  • Military family member - A person who is the spouse or child, regardless of age, of a military member or a former military member; or
  • Former military member - A person who served in the United States Army, Navy, Air Force, Marine Corps, or Coast Guard who declared and maintained Texas as the person’s state of legal residence in the manner provided by the applicable military branch while on active duty or who was killed in action or died while in service, or whose active duty otherwise ended.

People are released from the interest list on a first-come, first-served basis. Eligibility determinations are conducted when a person is released from the interest list.

When a person on an interest list transfers from one region to another, they must be added to the receiving region's list using the original intake date for the service as documented by the losing region. The staff person who first becomes aware that the person has transferred to another region, whether losing or gaining, is responsible for notifying the other region. This ensures that both regions' lists are accurate.

When a person is released from the interest list, the caseworker must contact the person to determine their continued interest in services and if interested, schedule a home visit if required by the service. If the person is no longer interested in services and voluntarily withdraws, the caseworker enters the appropriate CSIL closure code in the CSIL system. No entries in the Service Authorization System Online (SASO) are required, and Form 2065-A, Notification of Community Care Services, is not sent.

During routine interest list contacts, remove people on the interest list not living in Texas. Inform them they must be a resident of Texas to be on an interest list. Exceptions may be made for people on military assignments who are temporarily living out of state.

If the person is interested in services, the case will be processed as a routine intake.

Refer to the following for more information about the CSIL system:

2231, Community Services Interest List Bypass Criteria; and

2232, The Community Services Interest List System.

Note: The Area Agencies on Aging (AAA) can refer people to available services. Service needs, resources, and available service providers vary across the state. Not all the services identified by AAA may be available in every area. The applicant or person should contact the local AAA to determine if a specific service is available. To find the phone number for the local AAA, call 800-252-9240.

When the Texas Health and Human Services Commission (HHSC) intake staff determine a request is for STAR+PLUS Home and Community Based Services (HCBS), they may place the person on the STAR+PLUS HCBS interest list.

2230.1 Adding a Person's Name Back to CSIL

Revision 24-5; Effective Nov. 1, 2024

A person's name may be added back to the Community Services Interest List (CSIL) at any time within 90 calendar days after the CSIL service has been closed if the person contacts the Texas Health and Human Services Commission (HHSC):

  • within 90 calendar days of the closure date, the original date of request can be used; or
  • more than 90 calendar days following the closure date, the current date must be used.

If a CSIL closure occurred during release or assigned status and the person is added back to the interest list, the name may be released for eligibility determination, as needed, to ensure the region is fully utilizing its funding.

Any exceptions for adding names back to CSIL with the original date after 90 calendar days must be approved by the state office CSIL manager.

When an applicant or person has been denied for a service, the earliest date the applicant or person may be added back to CSIL for the same program is the date the applicant or person is determined to be ineligible or is no longer eligible for the program.

If the person's name is added back to CSIL before the last date of program eligibility, the CSIL interface match with the Service Authorization System Online (SASO) will cause the name to be removed from the interest list for that program. Example: A person's Family Care (FC) services are denied and end on Aug. 13, 2024. The first date the person can be added back to the FC interest list is Aug. 14, 2024. If the person is already on the Home-Delivered Meals (HDM) Interest List, the denial date for FC services would not impact the person's original date on the HDM Interest List.

2231 Community Services Interest List Bypass Criteria

Revision 24-5; Effective Nov. 1, 2024

Under certain circumstances, people can bypass the interest list to start the enrollment process. The bypass must meet specific criteria and be approved by the regional director.

2231.1 People Who May Receive Title XX Services with Regional Director Approval

Revision 24-5; Effective Nov. 1, 2024

A person may be given a bypass code to be placed at the top of the interest list, in the following circumstances. The regional director decides if the person may bypass the interest list and begin the enrollment process.

Personal Attendant Services (PAS)

People who meet the criteria for immediate or expedited intakes and need immediate service initiation may be given a bypass code and go to the top of the interest list. People in the following programs may be considered for the criteria:

  • Family Care;
  • STAR+PLUS Home and Community Based Services (HCBS) people denied STAR+PLUS HCBS;
  • people who have been denied Primary Home Care (PHC) due to loss of Medicaid; and
  • people denied Community Attendant Services (CAS) due to denial of financial eligibility by Medicaid for the Elderly and People with Disabilities (MEPD) for reasons other than failure to cooperate or refusal to sign up for the Medicaid Estate Recovery Program (MERP).

The criteria are:

  • the applicant has no available caregiver;
  • has personal care needs that are not being met; and
  • cannot go without personal care services for a full day; or
  • the applicant needs personal care, and the need for services has increased during the five days before the service request or will increase during the five days following the service request. Review 2310, Criteria for Immediate or Expedited Responses to Service Requests, for more information.
  • A person authorized for any Title XX service who is transferring to a new region is allowed to continue receiving that service.
  • A person in a STAR+PLUS HCBS Residential Care facility who is denied STAR+PLUS HCBS may go to CCSE Residential Care. If a bed is not available, the person is placed on the Community Services Interest List (CSIL) and given a bypass code to move to the top of the interest list.

All people meeting bypass criteria are placed at the top of the specific program interest list. Additionally, the bypass criteria will now apply to people meeting the criteria who are no longer eligible for STAR+PLUS or STAR+PLUS HCBS or people denied financial eligibility for CAS. The regional director will decide if a person can be released immediately or remain on the interest list until funding is available. The decision must be documented.

2231.2 Bypass Criteria for Additional Services

Revision 24-5; Effective Nov. 1, 2024

People in the following circumstances may be given a bypass code and placed at the top of an interest list. The regional director decides if the person can be released immediately or will remain on the interest list until funding is available. The decision must be documented.

  • Title XIX Day Activity and Health Services (DAHS) people denied Medicaid but who remain eligible for Title XX DAHS.
  • People in a STAR+PLUS Home and Community Based Services (HCBS) Residential Care facility who are denied STAR+PLUS HBCS may go to Community Care Services Eligibility (CCSE) Residential Care. If a bed is not available, the person remains at the top of the interest list until a placement is available.
  • People in a STAR+PLUS HCBS Adult Foster Care (AFC) who are denied STAR+PLUS HCBS may go to a CCSE AFC. If a bed is not available, the person is placed at the top of the interest list until a placement becomes available.
  • People denied STAR+PLUS HCBS who had received additional services through STAR+PLUS HCBS, such as Home-Delivered Meals or Emergency Response Services, may be given a bypass code for those services.
  • People authorized for any Title XX service that transfer to a new region are allowed to continue receiving that service.

2231.3 People Who May Not Bypass the Interest List

Revision 24-5; Effective Nov. 1, 2024

A person who has been denied Primary Home Care (PHC) because they do not need help with a personal care task should be placed on the Family Care (FC) interest list using the date of the PHC denial. They may not bypass the FC interest list.

People leaving a nursing facility are not eligible to bypass the interest list unless they meet the criteria for immediate or expedited as listed in 2231.1, Individuals Who May Receive Services with Regional Director Approval.

For people who have a temporary loss of categorical status or financial eligibility, follow the procedures in 3441, Loss of Categorical Status or Financial Eligibility, and 3441.1, Procedures Pending Reinstatement.

2231.4 Bypass Approval

Revision 24-5; Effective Nov. 1, 2024

The final decision on if a person is approved to bypass the interest list is made by the regional director or their designee rather than the regional budget officer or the contract manager. Releasing a name from the interest list and offering services to a person remains subject to available funding. 

2232 The Community Services Interest List System

Revision 24-3; Effective July 1, 2024

Interest lists for community care services are registered on the Community Services Interest List (CSIL) system.

Initial requests for services are documented using Form 2110, Community Care Intake, in the Long Term Care Service Intake (NTK) system, regardless  if funds for the requested service are available. If the person needs a service that is currently unavailable, use the interface on the NTK system or enter the person on CSIL. Complete and send the person:

Only people who live in the state of Texas may be placed on an interest list for Texas Health and Human Services Commission (HHSC) community services. An out-of-state address can be used as a contact if the power of attorney, guardian or legally authorized representative is living out of state.

Information provided by the person for the interest list must include a Texas address as the contact location for the person requesting services. Exceptions may be made for people who are temporarily out of the state due to military assignments.

Exceptions involving military members and military family members, as described in 2230, Interest List Procedures, apply when:

  • the applicant is a military family member living outside of Texas:
    • while the military member is on active duty; or
    • for less than one year after the former military member’s active duty ends; or
  • the applicant declines the offer of a Community Services program with an interest list and the applicant is a military family member living outside of Texas:
    • while the military member is on active duty; or
    • for less than one year after the former military member's active duty ends.

If the caseworker is making a home visit to assess the person for other services, it is preferable for the caseworker to help complete appropriate application forms at that time. If not, this task may be accomplished by mail. If Form 2111 and Appendix XXXV are mailed, they must be sent within two workdays of intake. Forms being filled out in person at the time of the home visit must be completed within the time frames as indicated in 2320, Case Worker Response, as determined by intake priority.

Within five workdays of intake, staff enter all relevant data into the CSIL. Staff may choose to use Form 2113, Community Services Interest List Registration and Follow-Up, to manually record interest list information to be data entered. Although use of Form 2113 is not mandatory, regional staff are responsible for entering all applicable data fields it contains into the CSIL.

Staff may not perform functional or financial determinations at the time the person is being added to the interest list, even if staff are not using the determination to screen the applicant off the interest list. If a person insists that they be assessed for eligibility immediately, even though staff have assured them that no funds are currently available, staff are required to do so. This action is considered an application, not an interest list case. All notification and civil rights procedures apply.

People on an interest list are contacted annually to confirm that they wish to stay on the list. Form 2247, Interest List Contact Letter, is mailed to the person.

If a person does not respond and no update is made to the annual contact date in CSIL within 120 days past the annual contact due date, CSIL automatically updates the person’s record as inactive. An annual contact is no longer required for people in an inactive status. A person with a status of inactive will not lose their place on the interest list. If or when the CSIL persons record is updated with a current contact date, the record will automatically go back into an active status.

The CSIL must also be updated within five workdays of the caseworker’s determination and the date that a completed Form 2065-A, Notification of Community Care Services, is mailed or given to the person. Within five workdays of the case action, the caseworker records if the case was certified, application denied or closed without application. If the case was closed or denied, the reason for closure or denial must be indicated.

Review Appendix XXV, Community Services Interest List (CSIL) Closure Code User's Guide, or the CSIL User’s Guide found on the intranet and for staff use only.

2240 Reserved for Future Use

Revision 24-3; Effective July 1, 2024

 

2241 Supervisor Responsibilities

Revision 24-5; Effective Nov. 1, 2024

CCSE unit supervisors ensure that their units have procedures for:

  • receiving service requests;
  • mailing applications to requesters of service, when appropriate; calling requesters to ensure that applications were received; and
  • instructing applicants, their families or both about completing applications;
  • assigning service requests to appropriate caseworkers within required time frames;
  • notifying caseworkers about applicants who may need help completing applications, when appropriate;
  • ensuring that the intake priority is accurate and reassigning the response category if documentation shows the need; and
  • monitoring and tracking requests for service, beginning with the date the request is received or assigned.

2242 Caseworker Responsibilities

Revision 24-5; Effective Nov. 1, 2024

CCSE caseworkers are responsible for the following:

  • establishing a date for a home visit by calling a person when feasible;
  • determining if the applicant is categorically eligible through Texas Integrated Eligibility Redesign System (TIERS) and printing verification if eligible;
  • mailing an application to the non-categorically eligible applicant who requires a routine response to their service request if the applicant can complete the form or has help available;
  • informing an applicant about the financial documentation, if any, that must be available at the time of the visit, such as verification needed when the applicant applies for Community Attendant Services (CAS);
  • requesting that a person with knowledge of the person's financial affairs be available at the time of the visit, if possible and appropriate;
  • requesting that the person's caregiver be present at the time of the visit, if possible;
  • mailing the appropriate letter; and
  • changing the intake priority if more information warrants. Document any changes made to the intake priority.

2243 Conflicts of Interest

Revision 24-3; Effective July 1, 2024

Texas Health and Human Services Commission (HHSC) staff control and direct significant amounts of public funds and must avoid the appearance of impropriety or conflict of interest. This applies to the awarding of Community Care Services Eligibility (CCSE) benefits and determining how these benefits are provided.

HHSC staff must not help a person receive CCSE benefits if the person is a relative either by blood or marriage, a roommate, dating companion, supervisor or someone under the person's supervision. Staff may not determine or redetermine eligibility, need for CCSE services or the amount of service a person may receive. HHSC staff may provide anyone with an application for services and inform them how and where to apply. It is also permissible to help any person gather documents needed to verify eligibility and the need for services. Staff must refrain from performing any other role in determining eligibility for CCSE services.

Caseworkers must consult with their supervisors if the person is a friend or an acquaintance. Generally, staff should not work on cases or applications involving these people, but the degree and nature of the relationship should be considered.

If staff have a relative either by blood or marriage, a roommate, dating companion or close friend who owns or is employed by a provider that contracts with HHSC to provide CCSE services, they must not demonstrate any special consideration toward that provider. Referrals of people to a provider must be based strictly on the person’s preference and the person's need for the service provided. In addition, instructions or lack of instructions to the provider about service delivery must be based solely on the person's needs and HHSC policy.

If a staff member suspects that a conflict exists, use intranet Form 2115 Conflict of Interest Notification, to notify the supervisor that a conflict of interest may exist that could result in an unethical or biased business relationship. The supervisor will record on the Supervisory Response section what action, if any, may be necessary and return the signed and dated form to the sender.

All CCSE staff are required to complete Form 2115 regardless of potential conflict of interest when:

  • hired;
  • the annual performance review occurs;
  • transferring between units or programs; and
  • assigned to another supervisor.

The form is also used to notify the first-line supervisor if a potential conflict of interest involves provider employees, people, even if staff are not involved in the eligibility determination for the applicant or person. Staff must complete Form 2115 if the potential conflict involves a person who is:

  • living in their home;
  • a dating companion;
  • their supervisor;
  • a relative; or
  • reporting directly to them.

2300, Responding to Requests for Service

2310 Criteria for Immediate or Expedited Responses to Service Requests

Revision 24-5; Effective Nov. 1, 2024

A person requires an immediate response to their service request if they:

  • have no available caregiver;
  • have personal care needs that are not being met; and
  • are unable to do without personal care services for a full day.

The following list gives examples of situations requiring immediate response. It is not intended to be all-inclusive.

The person:

  • 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 their need for total assistance in meal preparation or feeding.

A person requires an expedited response to their service request if they need personal care, they have no available caregiver, and their need for services has increased during the five days before the service request or will increase during the five calendar days following the service request. Example, the person:

  • 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 their caregiver within five calendar days of the request and has no available substitute.

All people 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. People with AIDS or HIV infection are often very ill and may need services initiated as soon as possible. Intake screeners and CCSE caseworkers must follow the procedures for immediate or expedited responses for all persons with AIDS or HIV infection who meet the criteria.

2320 Caseworker Response

Revision 24-5; Effective Nov. 1, 2024

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

If Applicant Requires Then the Program Standard is:
an immediate response,The caseworker the case is assigned to visits the applicant within 24 hours of being assigned the case. Example: The caseworker must respond to a case assignment received at 4 p.m. Tuesday by 4 p.m. Wednesday or must respond to a case assignment received at 11 a.m. Friday by 11 a.m. Saturday.
an expedited response,The caseworker the case is assigned to visits the applicant within five calendar days of the date of being assigned the case. Example: A response to a case assignment received on Wednesday must be by Monday, or a response to a case assignment received on Monday must be made by Saturday.
a routine response,The caseworker the case is assigned to visits the applicant within 14 calendar days of the date of being assigned the case. Example: A response to a case assignment on April 1 must be made by April 15.

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

If the applicant's health condition suddenly deteriorates, make every effort to get services for the person as soon as possible.

After talking with the applicant or family, the caseworker may alter the urgency of the request, if the change is made before the deadline for the intake priority. The caseworker 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
  • caseworker makes two attempted contacts within the designated period.
    • One attempted contact must be tried 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 tried face-to-face contact or an attempted phone contact with the applicant, their authorized representative, referral source or other knowledgeable party, if the intake does not identify an authorized representative for the applicant.

If the caseworker contacts the applicant to schedule an appointment and the applicant refuses and states they do not want services, the caseworker must close the intake in the Intake (NTK) system. The caseworker 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 caseworker 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 caseworker. For service control purposes, this standard should be measured by comparing the date and 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-calendar days is allowed for a routine referral, timelines cannot be used as a justification to delay contact with the person. If the two attempted contacts both occur near the end of the 14-calendar day period, the caseworker 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 caseworker makes the first attempted contact on March 11, and the second on March 14. To meet the program standard relating to timeliness of initial contact, the caseworker must document why the delay could not have been avoided.

2330 Scheduling the Initial Interview

Revision 24-5; Effective Nov. 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 typically 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, per Section 2431, Form 2060, Part A, Functional Assessment, and Section 4651, Assessing the Person’s Needs.

Caseworkers 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 caseworker 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 before the visit. If the person is not home for the scheduled appointment, the caseworker should leave contact information, such as a business card or letter, with the relevant office and caseworker contact information for the person. The caseworker should 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 caseworker may close the intake. The caseworker cannot close out the intake until at least the second business day after the second contact attempt. The caseworker needs to give the person time to contact them.

Example 1: Intake is assigned to the caseworker on Friday, March 2. On Monday, March 5, the caseworker mails an appointment letter for an appointment on the following Monday, March 12. The caseworker makes the home visit, but no one is home. The caseworker leaves a letter with the office and caseworker information on the door for the person. The caseworker followed up by attempting to contact the person by phone on Wednesday, March 14, but was unsuccessful and was 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 caseworker may close the intake since they made two attempts to contact the person. The caseworker may close the intake on the second business day after the second attempt or Friday, March 16.

Example 2: Intake is assigned to the caseworker on Friday, March 2. On Monday, March 5, the caseworker called and reached the person’s daughter, whose phone number is the only number listed on the intake. The daughter states she has a 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 caseworker verifies the address and asks if any other phone numbers need to be listed. The daughter verifies the address. The caseworker makes the home visit, but no one is at home. The caseworker leaves a business card with the caseworker and office information on the door for the person and her daughter. The caseworker 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 caseworker may close the intake on Tuesday, March 13, which is the second business day after the second attempt to contact the person.

If a caseworker contacts an applicant to schedule a home visit and the applicant states they have a contagious illness such as influenza, the caseworker must document the contact and the reason for the delay of the home visit, including the stated illness. If possible, the caseworker 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 caseworker must contact the applicant at least weekly until the home visit can be made. Each contact must be documented. 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 caseworker 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 calendar days after service initiation and make any necessary revisions to the service plan per Section 2663, Reassessment of Functional Need. Document the date of the home visit.

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

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 24-5; Effective Nov. 1, 2024

Refer the person to the appropriate agency or community resource if it is determined during the initial interview that they could use services from other agencies in the community. Thoroughly discuss the referral with them and their 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. Review Appendix XV, Services Available from Other State Agencies.

Always refer an applicant or person to the Social Security Administration if the person 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 a person to other agencies or other HHSC services, fully inform them about where they must go to apply. Help set up their appointment, if necessary. Provide the office address, phone number, name of the correct person to contact, and the appointment date and time, if known.

Provide I&R services to people regardless of their income. 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 People Under 21

Revision 24-5; Effective Nov. 1, 2024

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, applicants under 21 must meet all other eligibility criteria, including medical, financial, functional and unmet need.

Once a request for services from a person under 21 is received, the caseworker must contact the regional nurse and arrange for a joint visit for the initial home visit assessment. The regional nurse helps screen the person for medical need, determines if there are skilled tasks that the personal attendant cannot perform, and determines if 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.

Review Appendix XXXIII, Requests for Services from Individuals Under 21 Years of Age, for more information.

2333 Applications

Revision 24-2; Effective June 1, 2024

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

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

Examples

Example 1- Request for Services Only: A hospital social worker contacts HHSC for someone who is being discharged the following day. The social worker notes that the person lives alone and that they will need personal attendant services (PAS) because of their condition. In response to the social worker's call, an intake specialist contacts the person and they state that their daughter will be living with them during the weeks after their release from the hospital. The daughter will be able to provide all of their needs. They state that they will call HHSC if PAS is needed later.

This is not an intake. It is an example of an appropriately screened request for services when it is determined CCSE services are not currently needed. Although some information may have been recorded on Form 2110, Community Care Intake in the Intake (NTK) system, a caseworker 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 for Title XX services that do not require a home visit: A person contacts HHSC requesting Home-Delivered Meals (HDM). The intake specialist enters the information into the Community Services Intake List (CSIL) and completes the Form 2110 information in the Intake (NTK) system if the person is not currently receiving CCSE services.  When funds are available, the Title XX request is assigned to a caseworker. When the caseworker calls to set up an appointment, the person states they have changed their mind and do not want CCSE services. The caseworker records the correct denial code in the Community Services Interest List (CSIL) and if needed, closes the request in the Intake (NTK) system. There is no need to send Form 2065-A. No entries in SASO are required.

Example 3- Application: A person contacts HHSC and requests Community Attendant Services (CAS). The caseworker schedules a face-to-face home visit and upon arriving at the person’s home, the person states they are moving out of state and they do not need services. Because a face-to-face home visit was made, this is considered an application and the application denial must be entered in SASO. Form 2065-A is sent to the applicant.

2333.1 Required SASO Entries for Applications Withdrawn Early in the Process

Revision 24-4; Effective Sept. 1, 2024

All applications, including denials, must be entered in the Service Authorization System Online (SASO) within 30 calendar days of:

Review section 2611, Processing Time Frames, for more information.

If a person does not have an existing individual number in Texas Integrated Eligibility Redesign System (TIERS), the Create New Client function must be used.

Complete the required records in SASO: Address, Phone, Other Information, Case Ownership. Review section 8113, Records that Require User Entries - CCSE prior to completing the SASO Wizards.

Select the program or programs the person is applying for on the Service Request screen. Review section 8118, Service Request/Community Care – CCSE Services using the SASO Wizards.

Complete the Financial Wizard based on information reported on Form H1200, if received.  Review section 8120, Financial Wizard. If an application is being denied due functional eligibility and financial eligibility has not been determined, or Medicaid Eligibility for Persons with Disabilities (MEPD) has denied the CAS application, the caseworker may enter zeros in the financial information to proceed to the Functional Wizard.

Complete the Functional Wizard based on information obtained at the initial assessment. Review section 8130, Functional Wizard – CCSE.  Enter the intake date, assignment date, application denied date and select reason for denial on the interview screen. Explain the reason for denial by documenting in the Comment Section of the automated Form 2060. Click next until you get to the Eligibility Determination Screen.

The Eligibility Determination Window will appear with a pop-up box showing a list of errors. From this window click Generate, Close and Submit.

Within two business days add completed Form 2065-A in SASO to notify person of the denial. Review Form 2065-A Instructions and Attachment A and section 2810, Individual Notification Procedures.

2340 The Initial Interview and Application Process

Revision 24-2; Effective June 1, 2024

During the initial interview, the caseworker:

Review section 2347, Texas Medicaid Recovery Program, for additional information.

If the applicant can only sign documents with an "X," the caseworker completes the required documentation and then dates and initials the entry.

The caseworker must be alert for signs of abuse, neglect or exploitation when assessing people for CCSE services. Anyone with reason to believe a person who is elderly or a person 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).  Immediately notify APS of any reports received that indicate a person who is elderly or a person with a disability has been abused, neglected or exploited.

If a person who is applying for or is receiving CCSE services was 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. Review Appendix XV-E, Department of Family and Protective Services (DFPS), for more information.

2341 Financial Application Process

Revision 24-5; Effective Nov. 1, 2024

Applicants or their representatives must sign an application for assistance form when applying for services provided about income. Non-Medicaid applicants or their representatives applying for retroactive reimbursement for Medicaid-covered attendant services must also sign Form H1200, Application for Assistance - Your Texas Benefits. 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 receiving a completed, signed, and dated application.

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

The caseworker submits the written statement and the documentation with Form H1746-A, MEPD Referral Cover Sheet, with the application box checked. The caseworker must clearly note on Form H1746-A that the applicant is requesting to reapply for Community Attendant Services (CAS). The caseworker 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 caseworker will also be able to use Form H1200, Application for Assistance – Your Texas Benefits, on file for up to 90 calendar days following the denial date of Form 2065-A, Notification of Community Care Services. The caseworker 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 caseworker 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 caseworker needs to follow appropriate time frames for annual reassessments, as the annual reassessment is still 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 24-5; Effective Nov. 1, 2024

Form H1200, Application for Assistance-Your Texas Benefits, may be mailed if the applicant can complete it or has help available. If the applicant cannot complete the form, the caseworker must provide and help the applicant complete it at the initial interview.

If Form H1200, Application for Assistance-Your Texas Benefits, has been mailed to the applicant, the caseworker must, at the initial interview, review the form for completion and help the applicant complete the form, if necessary.

Ensure that the applicant completes the entire application, signs and dates it, and understands the penalties for fraud if the applicant deliberately gives false information. Do not make any changes to Form H1200, Application for Assistance-Your Texas Benefits, after the applicant has signed it.

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

  • bank accounts for community attendant services – bank name, account number and balance;
  • award letters showing the amount and frequency of income payments;
  • life insurance policy – the 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;
  • preneed funeral plans – the name of company, policy or plan number, and copy of the preneed agreement;
  • correct up-to-date phone numbers; and
  • power of attorney or guardianship – a copy of the legal document.
     

While it may not be possible to get everything on the list, the caseworker should gather all available information to prevent the applicant from a delay in certification. The caseworker should explain to the applicant that failure to submit the required documentation to MEPD could delay the 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 caseworker 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 caseworker may deny the application. The caseworker 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 caseworker enters: “HHSC is unable to make an eligibility decision within 30 calendar days due to your failure to furnish information.” The caseworker must document all contacts.

When an income-eligible person is receiving services with a form less than one year old,  and their spouse applies after them, the eligible person’s form may be used for their 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 24-3; Effective July 1, 2024

If Social Security or another program within the Texas Health and Human Services Commission (HHSC) has already made a financial determination for the applicant, 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
  • Texas Home Living waiver program

For categorically eligible applicants, the process is streamlined. Completion of the Application for Assistance form is not required. Instead, the date of the initial contact with the person is considered the date of application. This simplification is designed to make the process more efficient and less burdensome for the applicant.

Review 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 24-5; Effective Nov. 1, 2024

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 people receiving QI benefits do not qualify 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), 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 annual reassessment, caseworkers must check the Texas Integrated Eligibility Redesign System (TIERS) to determine if the person 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 people may not receive QI while receiving any other Title XIX-funded service. Inform the person that they can receive Title XX FC or Title XX DAHS at the same service levels. Receipt of QI services does not prevent applicants from being placed on any interest list.

Procedure for Ongoing People

Once it is known that a person receiving a Title XIX Community Care Services Eligibility (CCSE) service CAS, PHC, or Title XIX DAHS has been certified for QI benefits, the caseworker first determines if enrollment in Title XX FC or 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 person must be placed on a Title XX FC or DAHS interest list, the caseworker must contact the person to give them the choice of service they want to continue QI or Title XIX CCSE service.

The caseworker's next actions will depend on the person's decision:

  • If the person elects to continue receiving the Title XIX CCSE service, explain that this requires that their 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 about the person's decision.
  • If the person decides to transfer to a Title XX service to keep their QI benefits, grant that service if regional budgetary conditions allow without placing them on the interest list. Otherwise, the person should be placed at the top of the interest list. Title XIX service cannot remain open while the person waits for available Title XX funding.
  • 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 24-5; Effective Nov. 1, 2024

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

2342 Screening for Personal Attendant Services (PAS)

Revision 24-3; Effective July 1, 2024
 
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 authorization for FC. When appropriate, make a referral for PHC or CAS eligibility services.

Screening Initial Applicants

Before the initial interview, determine if the applicant is currently receiving Medicaid. 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's income and resources appear to be within the Supplemental Security Income (SSI) limits and they appear to have a medical need for help with personal care, refer them to the Social Security Administration (SSA) for an SSI application. However, staff should continue the referral for CAS 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. Help the applicant complete the form and get all required verifications that are available.

If the person cannot complete the application form during the interview, explain that it is essential 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 and 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

If a person or provider reports interim changes between annual reassessments, apply the screening exception criteria at the next annual review.

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 calendar 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 enrolling the person in STAR+PLUS is not mandatory, the transfer to PHC must be completed within 14 calendar days. If enrolling the person in STAR+PLUS is mandatory, 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 now meets CAS requirements, staff must help the person complete 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
Family Care Eligibility, 4420

2342.1 Receipt Date of the Application Form

Revision 24-5; Effective Nov. 1, 2024

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

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

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

2342.2 Timely Referral to MEPD

Revision 24-5; Effective Nov. 1, 2024

Before the initial home visit, staff must check Texas Integrated Eligibility Redesign System (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 entire application 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
  • keep 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 keep 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 Appendix V, Guidelines for Completing Form H1746-A, MEPD Referral Cover Sheet, to ensure the 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 24-5; Effective Nov. 1, 2024

The caseworker must screen all applicants for potential eligibility for Primary Home Care (PHC) and Community Attendant Services (CAS) before referring them to Family Care (FC). The caseworker applies the following exception criteria to decide 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 the unmet need policy does not prevent 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, continue the screening process.
  • Does the applicant receive Qualifying Individual (QI) benefits?
    • If yes, explain the benefit choices.  Review 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 chooses 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 need help with at least one personal care task?
  • Does the applicant have a medical condition causing a functional impairment when 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 caseworker will authorize FC while CAS financial eligibility is pending; or
  • it is 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 to request services, which is listed on Form 2110, Community Services Intake.

FC Services Pending the CAS Eligibility Decision

If FC enrollment is open in a region, the caseworker 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 caseworker must screen the person for CAS and refer to MEPD if screening criteria are met. The caseworker 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 caseworker follows the policy in Section 4652.3, Initial Referrals for Community Attendant Services, and negotiates a transfer from FC to CAS. The caseworker sends Form 2065-A, Notification of Community Care Services, noting the transfer of services. If the person is not eligible for CAS, the caseworker 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 caseworker 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 caseworker must tell the person that their application for services is denied and that they will be referred for CAS again if they reapply later. The caseworker documents all contacts 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 caseworker 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 interest list but must be told 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 refuses to cooperate with the financial eligibility determination process as described above, the caseworker must deny FC services. The caseworker documents all contacts 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 caseworker 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 person states that they cooperated and thought they submitted all requested information, the caseworker may check the Comments section in the Texas Integrated Eligibility Redesign System (TIERS). The caseworker may need to help the person get any missing requested documentation.

The person can reapply for CAS for up to 90 calendar days from the date of the MEPD denial without completing a new Form H1200, Application for Assistance – Your Texas Benefits. The caseworker must get a written, dated, and signed statement of request to reapply from the applicant or authorized representative to establish the date of application. The caseworker submits the written statement and the documentation with Form H1746-A, MEPD Referral Cover Sheet, marked Application. The caseworker must clearly note on Form H1746-A that the applicant is requesting to reapply for CAS. The caseworker 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, the person remains eligible for FC or is placed on the FC Interest List. The assigned staff enters 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 calendar days of the application date, the caseworker 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 caseworker:

  • 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 24-5; Effective Nov. 1, 2024

If a person states they will accept care only from their spouse, then the person may be assessed for Family Care services or placed on the Family Care interest list. They are not referred to Primary Home Care (PHC) or Community Attendant Services (CAS).

People 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 person must not be eligible to receive attendant care services funded through Medicaid", does not apply if the person elects to have a spouse attendant. Even though these people 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 caseworker must carefully evaluate tasks provided and tasks not currently provided by the spouse to determine the service plan purchased through Family Care services. Review Section 2513, Caregiver as the Paid Attendant, and Section 2514, Who Cannot Be Hired as the Paid Attendant, for more 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 caseworker must note the person is requesting the spouse as the paid attendant.

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

Note: Document the reason the person is not being referred to Primary Home Care (PHC) or Community Attendant Services (CAS) at each annual redetermination. Review Section 2342.3, Exception Criteria for Referrals to PHC or CAS.

2342.5 Disability Determination for People Under 65 Applying for CAS

Revision 24-5; Effective Nov. 1, 2024

The Texas Health and Human Services Commission (HHSC) caseworker 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 caseworker 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 caseworker 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 which detail the degree and history of the person's diagnosis. The caseworker must inform the person when scheduling the initial face-to-face contact that the caseworker will need the required evidence at their initial contact. If the caseworker schedules the face-to-face contact at least seven calendar days in advance, the caseworker 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 caseworker schedules the face-to-face contact less than seven calendar days in advance, the caseworker must present Form 2423 at the face-to-face contact. The caseworker must not delay the face-to-face contact to allow the person time to get the medical evidence.

The caseworker 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 caseworker adds note, 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 Rights and Responsibilities

Revision 24-4; Effective Sept. 1, 2024

During the initial visit with the applicant and their responsible party (RP), if appropriate, discuss the information in Form 2307, Rights and Responsibilities. Ensure the applicant understands the significance of their rights and responsibilities.

If the applicant seems unable to understand this information or the complaint process, giving the RP a copy of Form 2307 is essential. Sharing the applicant's rights and responsibilities with the RP is important if it appears the applicant cannot fully understand them. An RP may be a guardian, family member or other person who helps in the development of the service plan 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 they are not eligible for, the applicant may be prosecuted for fraud.

Rights and Responsibilities Documentation Requirements

At Application

At the initial visit, the caseworker must clearly and fully explain the information in the following forms to the applicant. Then, the caseworker must maintain copies in the case record and review them with the applicant or RP as shown in the instructions for each form.

People 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, they 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.
  • Form 1740, Service Backup Plan. Form 1740 is required when the service planning team determines a service is critical to the health and safety of the person. This includes people with priority status.

Review section 6000, Service Delivery Options, for complete information and requirements on CDS.

People 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:

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 person'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 person's services. Phone numbers and staff names do not constitute a change for completing a new Form 2307. It is important that the person knows how to reach the caseworker and business cards are suggested.
  • If the person's services change, they or the RP must receive 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 or 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 person's service plan.
  • Review and offer the choice of service delivery options at the annual reassessment.
  • Clearly document in the case record that the choice of service delivery options was reviewed at the annual reassessment.
  • Get a new signed and dated Form 1584 at any time the person changes their service delivery option. The caseworker also needs to complete and have the person sign Form 1581, Form 1582 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 person's copayment;
    • a change in priority status; or
    • termination of the case or service.

Note: All forms must be given to the person in their preferred language.

Review Appendix IX, Notification/Effective Date of Decision, for more 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 24-4; Effective Sept. 1, 2024

The Texas Health and Human Services Commission (HHSC) offers applicants and people two options for delivering personal attendant services (PAS). The caseworker is responsible for presenting information on the available service delivery options to the applicant at the initial interview and to ongoing people at the annual review, or when requested.

The service delivery options include the:

  • Consumer Directed Services (CDS) service delivery option, managed by the person;
  • Agency Option (AO), managed by the agency; and
  • additional casework procedures detailed in:

2347 Texas Medicaid Estate Recovery Program (MERP)

Revision 24-4; Effective Sept. 1, 2024

Under the Medicaid Estate Recovery Program (MERP), the state may file a claim against the estate of a deceased Medicaid recipient, 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 people 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).

Go to the MERP website for more information on the MERP.

Community Attendant Services

Form 8001, Medicaid Estate Recovery Program Receipt Acknowledgement (PDF), gives written information about 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, caseworker 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 caseworker on page 2;
  • 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
  • keep 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 show that they received and understand the MERP information. If the applicant, the responsible person or the AR, refuses to sign the Form 8001, caseworker must check the box on the bottom of page 2 to document the refusal and sign the Form 8001 to show that the MERP information was shared with the applicant.

When providing the written MERP information during the home visit or face to face contact, caseworker 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.

Caseworker 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 caseworker can determine if an applicant meets the grandfathered or exempt status.

Note: All forms must be given to the person in their preferred language.

Direct the applicant, the responsible person, or the AR to the contact information on page 2 of Form 8001 if they have more questions about the MERP.

2348 Retroactive Payments

Revision 24-5; Effective Nov. 1, 2024

The provider agency may be reimbursed for services provided before the date a completed, signed, and dated copy of HHS Form H1200, Application for Assistance – Your Texas Benefits is received:

  • for up to three months for a person without Medicaid eligibility at the time of the request for retroactive payment; and
  • for an indefinite period for a person who is Medicaid eligible at the time of the request for retroactive payment.

The caseworker must send the completed application to Medicaid for the Elderly and People with Disabilities (MEPD) for a decision about the applicant's financial eligibility.

Note: Someone who may complete or sign an application for an applicant or person may not be on the list of people to whom HHSC can release the applicant's individually identifiable health information. Review Section 1150, Personal Representatives, for people 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 person does not have to complete an application when requesting services. Also, a person who requests facility-initiated Day Activity and Health Services (DAHS) does not have to complete an application if they have stopped receiving services by the time they are contacted. The DAHS facility can be reimbursed for facility-initiated DAHS provided to a person who was Medicaid eligible when service was received, even if the person does not complete an application.

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

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

If the person refuses to participate or allow the caseworker to process the initial paperwork:

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

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

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

2349 Procedures for Applicants Aging Out of PCS to PHC

Revision 24-5; Effective Nov. 1, 2024

The Texas Health and Human Services Commission (HHSC) has an agreement with the Texas Department of State Health Services (DSHS) that people receiving Personal Care Services (PCS) are referred for Primary Home Care (PHC) two months before their 21st birthday. Review Appendix XXXIII, Requests for Services from People Under 21 Years of Age, for more information and a listing of DSHS offices.

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

Since there are differences between PCS and PHC services, the HHSC caseworker thoroughly explains the allowable PHC services at 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 applicant's 21st birthday. PCS services should end at midnight the day before the applicant's birthday. Coordinate the transition with the PCS caseworker and applicant to ensure there are no gaps in services.

All time frames are applicable, and intake processing must not be delayed. The caseworker 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 before the person's 21st birthday.

Upon receipt of Form 3052, Practitioner's Statement of Medical Need, and the final eligibility determination, the caseworker negotiates the start of care date for the person'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 person's 21st birthday, the caseworker is allowed up to five business days after the 21st birthday to complete the data entry.

If the PCS Person Is Ineligible for PHC

If the person 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 People 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, they 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.

2400, Assessment Process

2410 Overview of the Assessment Process

Revision 24-3; Effective July 1, 2024

The assessment process determines if the applicant meets all eligibility requirements, including:

  • financial eligibility;
  • functional eligibility; and
  • having an unmet need for services.

The assessment process should produce a case record that clearly documents the results of the caseworker's determination. All processes that can be performed in the Service Authorization System Online (SASO) Wizards must be performed in the system to consider that action complete, including:

  • Form 2059, Summary of Client's Need for Service;
  • Form 2060, Needs Assessment Questionnaire and Task/Hour Guide; and
  • Form 2064, Eligibility Worksheet.

Note: When a caseworker receives a request to add an additional service to a person already receiving services, they must assess the person to determine that they meet all eligibility requirements for the additional service. This includes determining financial and functional eligibility and having an unmet need for the service. Review 7310, Requirement to use SASO Wizards, 8120, Financial Wizard, 8130, Functional Wizard and 8140, Authorization Wizard.

2411 Required Documentation

Revision 24-5; Effective Nov. 1, 2024

The following must be documented in the case record:

  • A person’s eligibility based on their categorical status in the Texas Integrated Eligibility Redesign System (TIERS) or current financial and functional status using Form H1200, Application for Assistance – Your Texas Benefits, Form 2060, Needs Assessment Questionnaire and Task/Hour Guide or Form 2064, Eligibility Worksheet.
  • A person’s medical, social, environmental, or physical conditions relevant to their functional status using Form 2110, Community Care Intake, Form 2059, Summary of Client's Need for Service, Form 2060, and the case narrative.
  • A person’s degree of self-sufficiency and the tasks they can perform using Forms 2110, 2059 and 2060.
  • Environmental adaptations that are being used or could be used to help the person achieve or maintain their maximum level of self-sufficiency using Form 2059.
  • People who are resources, including family, friends, and community networks, that the person now uses or who are available to perform or help with activities of daily living using Form 2059 and Form 2060, Part A.
  • Agency resources in the community available to provide any of the services needed by the person using Form 2059 and Form 2060, Part A.
  • Form 8001, Medicaid Estate Recovery Program Receipt Acknowledgement, for Community Attendant Services applicants or responsible parties.

In some areas of Texas, the Area Agency on Aging (AAA) may submit a completed Form 2060 based on the assessment of services it provides. If a completed Form 2060 is received, review the information as part of the assessment process.

Note: Review Section 3000, Eligibility for Services for detailed explanations of financial eligibility assessment and determination procedures.

2420 Reserved for Future Use

Revision 24-3; Effective July 1, 2024

 

2421 Review of the Community Care Intake Form

Revision 24-5; Effective Nov.1, 2024

Review Form 2110, Community Care Intake, for all relevant information. Make sure the practitioner is the applicant's current practitioner and that the name, address and phone number listed are correct. If the applicant provided a rural route address, ask for the updated street address. If the person states they do not have a new address, continue to use the address provided. Take no action if the street-style address is not provided. Ask the person to update their information with the Texas Health and Human Services Commission if they are notified by the U.S. Postal Service of a new address.

Verify that the responsible party is the primary contact for the applicant and that the name, address, and phone number are correct. On Form 2110, list any other family members or informal supports who can be contacted if the applicant cannot be reached. Review the requested services and address those during the interview and in the documentation.

2422 Form 2059, Summary of Client's Need for Service

Revision 24-5; Effective Nov. 1, 2024

The purpose of Form 2059, Summary of Client's Need for Service, is to document the applicant's:

  • medical diagnosis and physical condition;
  • functional limitations;
  • home environment;
  • living arrangements; and
  • family and community supports.

Record all information reported by the applicant or informal supports during the home visit on Form 2059-W, Summary of Individual's Need for Service Worksheet. This information is entered into Service Authorization System Online  (SASO) and will generate Form 2059.

Carefully observe and use interviewing skills during the initial home visit and throughout the assessment process. This is necessary to collect critical information about the person's functional and mental abilities, as well as community and family resources. People may demonstrate functional abilities while responding to questions about their home and living environment or medical problems. They may reveal information about family resources while responding to questions about financial eligibility. They may reveal intellectual and developmental disabilities or lack of mental clarity in the way they respond to questioning throughout the interview. During the interview, be alert for any indications of abuse, neglect or exploitation. If any of these conditions are present, refer the person to the Texas Department of Family and Protective Services (DFPS), Adult Protective Services.

2422.1 Medical Diagnosis and Functional Limitations

Revision 17-1; Effective March 15, 2017

Ask the applicant for information regarding his medical diagnosis and physical and functional limitations. Record this information on Form 2059-W, Summary of Individual's Need for Service Worksheet.

2422.2 Home Environment

Revision 24-5; Effective Nov. 1, 2024

The person's functional status is always relative to the home circumstances where the person performs the activities of daily living. For example, the person may have physical limitations that would not affect their abilities to perform specific personal care tasks if they lived in a home complete with all modern conveniences. If, however, their home contains only minimal household equipment, their inability to perform their personal care tasks could be compounded. Always assess a person's functional capacity in relation to the home environment where the tasks are performed daily. Service plans are developed to be carried out in specific home environments and each plan should relate specifically to a functional assessment done in that environment.

Observe and ask questions about the person's home and immediate environment to assess their ability to perform activities of daily living. Determine if the environment affects the person's ability to perform these activities or otherwise affects their health and safety.

Guidelines for Assessing the Home Environment

Using the following guidelines, assess the home environment and document the results on Form 2059-W, Summary of Individual's Need for Service Worksheet, to be entered in the Service Authorization System Online  (SASO). When observing the person's home and immediate environment, assess the following:

  • Does the structure of the house or dwelling create an environment that is safe and adequate for the person's unique needs?
  • Are there assistive devices and equipment necessary for the person to live safely or that would improve their safety? Note: These include ramps, grab bars, wide doors, lowered light switches, and adequate light for safe visibility.
  • Is the home clean enough and orderly enough to be safe for the person's lifestyle?
  • Does the home pose any critical health hazards?
  • Do they have neighbors who are or might be resources for helping with any special monitoring the person might need because of a unique health or physical problem?
  • Is the neighborhood safe to allow the person to move safely in and out of their home as needed?
  • Is the person safe from physical harm in their own home?

Home Arrangement

Is the person the owner of their home, or do they live in an apartment or with friends or relatives? The person may pay rent, own the home or live cost-free.

Is the person homeless and no friend or relative is available to provide a home? If the person has insufficient income to rent a suitable home, they may be living in a public shelter or an exposed setting. Refer the person to Adult Foster Care (AFC), Residential Care (RC), public housing, or other community living resources. A referral to Adult Protective Services (APS) may be needed.

Home Condition

Is the person's home:

  • Adequate — Physically safe and arranged or equipped so the person lives safely and performs normal activities of daily living? Although adjustments may be desirable, they are not necessary for safety.
  • Inadequate Questionable — The residence presents serious limitations conducting activities of daily living, or safety hazards exist because of a need for major repairs, addition of utilities, or assistive devices. Check the appropriate boxes on Form 2059-W.
  • Inadequate Unsafe — The residence is an unsafe environment for the person. The structure is in a severe state of disrepair, contains critical health hazards, or prevents one from performing the normal activities of daily living. The person may need to be moved for their health and safety. A referral to APS may be appropriate. Check the appropriate boxes on Form 2059-W.

2422.3 Living Arrangement

Revision 24-5; Effective Nov.1, 2024

The caseworker documents on Form 2059-W, Summary of Individual's Need for Service Worksheet, Item 4, if the applicant lives alone, with a spouse, with family or friends, or if they are in adult foster care or a residential care facility. In Item 5, list the name and relationship of all household members and indicate with a Y that they are in the household. Note if any of the household members receive services or are applying for services.

2422.4 Documentation of Caregivers

Revision 24-5; Effective Nov. 1, 2024

Ask the person if they receive help with their activities of daily living and list the names and relationships of all caregivers. These people may be family members, friends or neighbors. List the tasks performed by each caregiver on Form 2059-W, Summary of Individual's Need for Service Worksheet. Under Caregiver Status, indicate if there is a reason the caregiver cannot meet all the person's needs, such as working full time, having ill health, needing caregiver support, or providing continual care. For household members who are not performing any caregiver tasks, leave the caregiver status blank. If a household member states they are unwilling to help the person with any tasks, note this in the Caregiver Status on Form 2059-W.

The caregiver will be assessed during the functional assessment. Review Section 2433.1, Assessment of the Caregiver.

Determine if the caregiver needs caregiver support as defined in Section 2512, Caregiver Support, and develop the service plan accordingly.

2422.5 Attendant Policy for People Transferring from Another Personal Attendant Services (PAS) Program

Revision 24-5; Effective Nov. 1, 2024

For people applying for Community Care Services Eligibility (CCSE) personal attendant services (PAS) and the caregiver has been the paid attendant in another HHSC program, the following guidelines must be applied to people who are transitioning from the following programs:

  • People who are no longer eligible for STAR+PLUS or the STAR+PLUS Home and Community Based Services (HCBS) program, who are being assessed for Primary Home Care (PHC), Community Attendant Services (CAS), or Family Care (FC); and
  • People transitioning from the Texas Health Steps Comprehensive Care Program (THS-CCP) Personal Care Services (PCS).

The applicant must meet the unmet need criteria, but the current circumstances will be considered.

During the initial interview, if the caregiver has been the ongoing paid attendant and would like to continue as the paid attendant, the caseworker will ask the caregiver the following question: "Would you continue to provide care if you are not being paid to provide the care?"

If the response is "No," determine the tasks the caregiver has been paid for in the previous program and if the person still needs help with those tasks. Determine which tasks will continue as caregiver tasks and develop the service plan accordingly. Document the caregiver's response and send Form 2067, Case Information, along with the referral packet, to the provider advising that the caregiver had previously been the paid attendant and is eligible to be the paid attendant.

If the response is "Yes," evaluate if there is any unmet need or if caregiver support is required. If services continue, the caregiver cannot be hired. If there is no need for caregiver support or no unmet need, the applicant is denied services.

Caseworkers must follow this policy for people applying for HHSC Primary Home Care (PHC), Community Attendant Services (CAS), or Family Care (FC) who are transitioning from one of the programs listed above.

2422.6 Common Household Tasks, Duplicate Services and Services Provided to Other Household Members

Revision 24-3; Effective July 1, 2024

If a person lives with others, do not purchase services that are normally provided as part of the household routine. Examples are meal preparation, shopping, laundry, and housekeeping for the person, unless the person has unique needs.

If a person lives with others, determine if they need unique tasks performed apart from the household's tasks and if performing these tasks imposes more burdens of time and responsibility on the household members. Unique tasks are attributable to the person's problems. Examples include incontinence, a need for a special diet, food preparation, extra shopping or special housecleaning caused by the person's behavior. Allowable tasks also include cleaning up after personal care tasks, cleaning the person's room and the bathroom used by the person. If it is determined the person's needs impose special and extra activities on the household members, document these needs on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide.

Services Provided to Other Household Members

Identify if services are being provided to any other household member by the Texas Health and Human Services Commission (HHSC) or another agency. If services are being provided, assess if they meet some of the person's needs and would affect their service plan.

Example: A person’s spouse receives Community Care Services Eligibility services, and an attendant performs housecleaning, laundry, and meal preparation as part of that service plan. Some of those services also benefit the spouse or duplicate services that they need. In this case, divide the time for common tasks between the people and authorize the task for both people. Refer to the maximum times listed on Form 2060 for companion cases.

Refer to Section 4400, Family Care Services, and Section 4600, Primary Home Care and Community Attendant Services, for specific information about situations when two people in the same household receive attendant services.

2422.7 Assessment of Social and Community Resources

Revision 24-5; Effective Nov. 1, 2024

Assess the person's community and social network resources, such as churches, civic clubs, and voluntary affiliations, to determine if any of these entities provide services or can do so. Also, identify available service agencies that serve older people and people with disabilities and might be able to provide a service needed by the person. Always determine if any of these sources can help the person before services from the Texas Health and Human Services Commission (HHSC) are authorized. Review Appendix XV, Services Available from Other State Agencies, for help identifying alternate sources of assistance. When possible, refer to local resource directories for information about services in a person's community. Document the use of or referral to other service agencies on Form 2059-W, Summary of Individual's Need for Service Worksheet.

All other services available to the person must be considered and used before HHSC services are authorized.

2423 Guardianship

Revision 24-3; Effective July 1, 2024

A Community Care Services Eligibility person may need a guardian if they:

  • appear to be incompetent; or
  • are incapacitated and cannot care for themselves or manage their property and financial affairs.

If the person's incompetence or incapacity results in them being in a state of abuse, neglect or exploitation, the caseworker must make a referral to Adult Protective Services (APS). Unless ordered by a court to do so, the caseworker must not file a petition for guardianship or assume guardianship of the person or the estate of a Texas Health and Human Services Commission (HHSC) person.

If the court intends to appoint the caseworker as guardian, the caseworker must advise the court that serving in that capacity will violate HHSC policy. If the caseworker is appointed guardian by the court, the supervisor and regional attorney must be notified immediately. If a referral to APS, Texas Department of Family and Protective Services, has not been made, make one now.

2430 Functional Assessment

Revision 24-3; Effective July 1, 2024

Use Form 2060, Needs Assessment Questionnaire and Task/Hour Guide to determine the following:

  • the person's functional eligibility;
  • their ability to carry out activities of daily living;
  • what they should continue to do for themselves to maintain their current level of self-sufficiency;
  • what they cannot do for themselves because of physical limitations, mental limitations or both;
  • which resources are available to help with specific tasks;
  • if the person has an unmet need; and
  • how much service the person will receive, if eligible.

A person's functional level is based on:

  • their physical condition;
  • their medical problems and the functional limitations they impose;
  • their mental clarity and limitations and the effect they have on performing activities of daily living; and
  • the condition of their home environment.

The age of the person being assessed for services should not be considered when determining the level of functional need. Example, the applicant is a 3-month-old infant whose mother is applying for Community Attendant Services (CAS) for the child. The infant will need help with most of the activities of daily living and would, therefore, score a 3 on those tasks. The fact that the functional need is the direct result of the person's age should not be considered when assigning a score for the task.

If the person appears eligible for Community Care Services Eligibility services based on age, income, and resources, and they request services beyond information and referral, complete Form 2060, Part A, to determine the functional eligibility for services. This assessment helps determine if the person has functional needs, what kinds of functional limitations they experience, which tasks they need help with, and if their mental clarity contributes to their need for help.

Related Policy

26 Texas Administrative Code Section 271.63(a)

2431 Form 2060, Part A, Functional Assessment

Revision 24-3; Effective July 1, 2024

Program Standard: The caseworker must score each item on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, Part A, Functional Assessment. They then must accurately compute the total score to determine if the person is eligible for Community Care Services Eligibility services. Use the spaces under each item, as needed, to explain the person's limitations or their accommodations for their disability. Refer to the form instructions for detailed information about scoring Form 2060, Part A. Appendix XVII, Service/Score Code Guide, which indicates the score requirement for each service.

During a face-to-face interview, ask the person each question on Form 2060, Part A, as the question is stated on the form. Then, ask more questions to gain a complete understanding about the degree of the person's ability or inability to carry out activities of daily living. Careful assessment of the person reveals what they can do for themself, what they should continue to do for themself to maintain their current level of self-sufficiency, and what they cannot do for themself because of physical limitations or mental limitations. When conducting an assessment, use the following scale of disability and follow the detailed definitions of impairment levels found in the instructions for Form 2060, Part A.

Scale of DisabilityDefinitions of Impairment Levels
0No impairment. The person can conduct activities without difficulty and does not need assistance.
1Minimal or mild impairment. The person can conduct activities with minimal difficulty and needs minimal assistance.
2Extensive or severe impairment. The person has extensive difficulty carrying out activities and needs extensive assistance.
3Total impairment. The person is completely unable to carry out any part of the activity.

To determine the severity of the person's impairment, consider the following factors:

  1. Person's Perception of the Impairment — Does the person view the impairment as a major or minor problem?
  2. Congruence — Is the person's response to a particular question consistent with the person's response to other questions and consistent with what has been observed?
  3. Person’s History — Probe to understand the person's history about the current situation and the person's attitude about the severity of the impairment. For example, has the person  always kept a messy house and is not concerned because they cannot perform housekeeping tasks? Has the person always eaten only one meal a day and is not interested in eating more often? How has the impairment changed the person's lifestyle?
  4. Person's Right to Self-Determination versus Danger to Self — Consider the consequence to the person if they choose not to take medications, bathe or adhere to a special diet.
  5. Lack of Facilities — Absence of facilities for bathing, laundry, phone calls or meal preparation may indicate an impairment. The impairment and its degree will depend on the person's accessibility to the facility, ability to use it and ability to make satisfactory accommodations in the absence of the facility.
  6. Adaptation — If the person has adapted their physical environment or clothing to the extent that they are able to function without help, the degree of impairment will be lessened. However, the person will still have an impairment.
    Note: Medication is not considered an adaptation to the person's functioning like a walker is. The person is not considered to have an impairment if the medication is working. The person is rated on how they are functioning at the time of the interview, regardless of the status of taking medication.

The following chart provides a general guide for assessment. Whether the person is taking medication, forgetting or refusing medication, or taking medication incorrectly, they are still assessed on their current level of functional ability.

Situation: The person has problems with dizziness and balance, which could affect scoring on the transfer or ambulation and balance questions.

If the person:then:
is taking medication and has no problems with dizziness,score 0 on impairment.
is taking medication but still has occasional episodes of dizziness,score 1 on impairment.
is taking medication but still has significant problems with dizziness and balance,score 2 on impairment.
has a prescribed medication but is forgetting to take the medication or is taking the medication incorrectly,the person is still assessed based on their current level of functioning.

The caseworker must document the reason in situations where the task score on Form 2060 is inconsistent with the amount of time allotted for that task. Example: A case reader may decide to rate Standard 10 unmet if a person scores 1 on all Form 2060 tasks, yet the maximum amount of hours for each are purchased and case documentation does not explain the discrepancy.

2432 Scoring Persons Who Cannot Respond

Revision 24-5; Effective Nov. 1, 2024

On some occasions, the caseworker may need to assess small children, infants, or people who are unconscious or otherwise non-responsive. Use Form 2060, Needs Assessment Questionnaire and Task/Hour Guide to conduct these assessments. Allow the caregiver to respond if the person cannot. In scoring each item, use the caregiver's response, the caseworker's observations, and any knowledge the caseworker may have about the person from other sources.

2433 Determining Unmet Need in the Service Arrangement Column

Revision 24-5; Effective Nov. 1, 2024

Regardless of a person’s functional eligibility as determined by their score on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, they can only receive CCSE services if they have an unmet need for those services.

Unmet need is defined as a requirement for assistance with activities of daily living that cannot be adequately met on an ongoing basis by friends, relatives, volunteers, or other service agencies.

For any task listed on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, the Service Arrangement Column will determine if the person has an unmet need to assess their overall eligibility based on unmet need. Review questions 1 through 15 and ask the person the following additional questions.

If the impairment score is 1 – Ask the person if they can perform the task by themselves, even though it may be difficult for them.

  • If the answer is Yes, enter S in the service arrangement.
  • If the answer is No, ask the person who helps them with this task. If the person states that a caregiver helps them, enter C for Caregiver in the service arrangement. List the caregiver's name, relationship, and task on Form 2059-W, Summary of Individual's Need for Service Worksheet, if it is not already entered.
  • If the person states they receive help from another agency, enter A for Other Agency in the service arrangement. List the name of the agency on Form 2059-W.
  • If the answer is No and the person states they have no help from any source and needs help to perform the task, enter P for Purchased in the service arrangement.

If the impairment score is 2 or 3 – Ask the person if they receive help with this task.

  • If the answer is Yes, ask the person who helps them with the task. If the person states a caregiver helps with the task, enter C for Caregiver in the service arrangement. List the caregiver's name, relationship, and task on the worksheet, Form 2059-W, if it is not already entered.
  • If the person states they receive help from another agency, enter A for Other Agency in the service arrangement. List the name of the agency on Form 2059-W.
  • If the answer is No and the person states they have no help from any source and needs help to perform the task, enter P for Purchased in the service arrangement.

If the person states they receive some help from others, but it does not meet all their needs for a specific task, enter P/C. Document the part of the task performed by the caregiver in the Tasks Performed section on Form 2059-W.

Related Policy

26 Texas Administrative Code Section 271.63(b)

2433.1 Assessment of the Caregiver

Revision 24-5; Effective Nov. 1, 2024

For each task marked C on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, assess the capability, dependability, availability, and willingness of the caregiver. Consider and discuss family and job responsibilities, and the physical demands of caregiving. For each task, determine by observation and by asking the applicant or caregiver the following questions:

  1. Is the caregiver physically and mentally able to perform the task?
  2. Is the caregiver dependable in performing the task on the required schedule?
  3. Is the caregiver available at the time the person needs the task performed, either scheduled or on-demand?
  4. Is the caregiver willing to perform the task on a regular and ongoing basis?

It may be necessary to talk with the person's current caregiver to assess their contribution to the person’s care needs accurately. If the caregiver cannot join the applicant for the initial face-to-face visit, get as much information as possible from the applicant and contact the caregiver by phone to verify that the caregiver is willing to provide the tasks. Do not delay service initiation if the caregiver cannot be reached.

If, for any task, it appears the caregiver cannot adequately meet the applicant's needs or it is apparent from caseworker observation that the task is not being adequately performed, discuss with the applicant if some or all of the task should be purchased.

Be sensitive to any indications of abusive or neglectful behavior on the part of the caregiver, and, if necessary, make a referral to Adult Protective Services.

2433.2 Exploring Other Resources for Meeting the Applicant's Needs

Revision 24-5; Effective Nov. 1, 2024

Explore other possibilities for resources with the person. Ask if family members pay someone to help the person and if the current help is enough. Use observations about the caregiving arrangement to determine if needed tasks are being adequately performed. If a person's need for help with a particular task is being adequately met and the help is expected to continue, do not authorize purchased services for that task. If the need for help with a particular task is not being met or is only partially met, ask the person and family if there is anyone who would voluntarily provide the needed help. Explore the use of any identified volunteers. If voluntary help cannot be obtained, explore the use of community resources, and consider service options from other groups or agencies. Review Section 2535, Involvement of Volunteer Resources, and Section 2530, Other Resource Services, for possible resources to meet the person's needs. If the person's need for help cannot be met in any other way, enter P for the task on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide. If Home Delivered Meals is the only service being purchased, complete the service arrangement column and do not allocate time on Form 2060.

If a person's needs for help are now being met and the person or family determines the present care arrangements cannot be continued, inform the person or family that the person may reapply for services when the current arrangement is discontinued. If, during the initial interview, the person or their family knows the present care arrangements will discontinue within 30 calendar days, proceed with the application process.

Examples:

  • A person's sister, who is providing the care, has taken a job and will begin work on a specified date.
  • A live-in relative who is providing the care plans to leave town on a specific date.
  • A family member has been paying a caregiver but will soon be unable to continue because of new financial obligations, which will begin on a specific date.

If someone who has been paying for care intends to discontinue the arrangement on a specific date within 30 calendar days, proceed with the application. Otherwise, offer to take an application at the time the care arrangement is discontinued. If someone will continue to purchase some of the care, determine if the applicant has an unmet need for any more care. If someone is willing to pay for services only while the person is on an interest list, this does not affect the person's unmet need for services purchased by the Texas Health and Human Services Commission (HHSC). However, if someone is willing to pay for services after the person comes off the interest list, there is no unmet need.

In some situations, a caregiver may quit employment to stay home and provide care for the applicant and is requesting to be the paid attendant. In this situation, the caseworker must get verification that the person quit employment within 30 calendar days before or after the application date. The caregiver may be considered as a potential attendant. In the Service Arrangement column of Form 2060, note the tasks that the caregiver will voluntarily provide and those tasks that will be purchased. Review Section 2513, Caregiver as the Paid Attendant, for more information.

This policy also applies to ongoing cases where a caregiver who has been working full-time quits to stay home and provide care for the person. The caseworker must get verification that the person quit employment within 30 calendar days of the request for the change.

When the Service Arrangement Column of Form 2060 is completed, review the results to determine if the person has an unmet need. If all responses are S, C or A, the person has no unmet need and is not eligible for services. Advise the person that they are not eligible at this time and that they may reapply if their circumstances change. Be sure to adequately document this information in the Service Authorization System Wizards with the appropriate denial code and send the applicant Form 2065-A, Notification of Community Care Services.

If there are tasks marked P on Form 2060, continue to the Task and Hour Guide section.

2434 Support Score and Establishing Priority

Revision 24-5; Effective Nov. 1, 2024

If an applicant for Primary Home Care (PHC), Family Care (FC), or Community Attendant Services (CAS) has a functional score of 3 and the service arrangement for a priority task feeding, toileting, transfer, meal preparation is a P, then a support score must be entered for these tasks on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide. Determine the likelihood of that task being done if the attendant does not show up during a typically scheduled service shift. Using the following scale, enter the score in the Form 2060 Support Score box by the appropriate item.

Functional ScoreSupport Score
1It is very likely that the task would be done even if the attendant does not show up.
2= The task will probably be done if the attendant does not show up.
3The task will probably not be done if the attendant does not show up.
4It is very unlikely that the task will be done if the attendant does not show up.

In determining this support score, do not consider caregivers as available if they would be at work or school, even if they could come to the person's home if the attendant were not there. Do not enter a support score for an item if either the task is not purchased or the person's score for that task is not "3."

If the support score is 4 on any of the priority tasks, the person will be designated as a priority person. Review Section 2540, Priority Status People for more information on this designation process.

2440 Use of Form 2060, Part B, Task/Hour Guide, and Part C, Task/Minute and Subtask Guide

Revision 24-5; Effective Nov. 1, 2024

For all personal attendant services (PAS) cases, the caseworker uses Part B and Part C of Form 2060, Needs Assessment Questionnaire and Task/Hour Guide to determine the number of purchased services needed by a person.

The Part C, Task/Minute and Subtask Guide, provides a uniform approach to the authorization of services based on a minute range per task and impairment score. Each impairment score for each task has a minimum and maximum allotted time. It is mandatory to follow the minute guideline and check the subtasks for each task to document the type of help needed and to support the time allocated for that task. Review the Form 2060 Instructions for complete directions for completing the form.

Form 2060, Pages 1-5, must be manually completed during the home visit initial assessment for an applicant who will receive PAS. Review the Task/Minute and Subtask Guide at each reassessment and initial the form. When there is a change in hours, either complete a new Form 2060 manually or update the current Part B and Part C.

Refer to Form 2060, Part C, for guidelines on the number of minutes to be allowed per task. The amount of time allowed for any task should be determined by accounting for:

  • the amount of help the person will usually need;
  • the availability of anyone else to help with the task;
  • which specific subtasks and activities need to be purchased;
  • environmental and housing factors that may hinder, or facilitate, service delivery; and
  • the person's unique circumstances.

Discuss each task thoroughly with the person to decide if they need help with it, how much time is required to perform it, and how often each week the task must be performed. The total time allowed for each task must be within the minimum and maximum time limits for the impairment score, indicated on Form 2060.

Negotiate service authorizations with people to reach an agreement about:

  • the number of tasks and activities the person needs help with;
  • how often the help is needed; and
  • the amount of time needed by the provider to carry out those tasks and activities per week.

All appropriate subtasks must be checked to show the specific tasks the person needs. A person scoring a 2 or 3 may need all subtasks under the impairment score of 1 and additional subtasks under the impairment score of 2. The time allotted must be within the range of the impairment score.

Time above the minute range may only be allotted with documented supervisory approval. Time below the minute range may be allotted with documentation of the person’s extenuating circumstances.

2440.1 Requesting Supervisory Approval for Time Above the Minute Range

Revision 24-3; Effective July 1, 2024

When a person has extenuating circumstances and requires a deviation in the time range, the caseworker must request supervisory approval to authorize time above the minute range for the task or impairment score. The caseworker must document why the person requires minutes outside the range for the task or impairment score level. The deviation must be discussed verbally or by email with the supervisor, and the supervisor must approve or disapprove the deviation.  The caseworker must document the supervisor's approval date on Form 2060 in SASO.

Refer to 2441, Circumstances When Supervisory Approval is Not Required.

2441 Circumstances When Supervisory Approval is Not Required

Revision 24-5; Effective Nov. 1, 2024

In some situations, the person may have extenuating circumstances and a compelling reason that require subtasks in a lesser impairment score to be authorized for a task. The two situations where the caseworker may allot time for subtasks in a lesser impairment score without supervisory approval are if the person has:

  • extenuating circumstances and is requesting only subtasks in a lesser impairment score; or
  • a caregiver or other agency providing some of the subtasks.

The caseworker documents:

  • the person's extenuating circumstances and the reason tasks with a lesser impairment score are authorized; or
  • the part of the task the caregiver or other agency provides.

2441.1 Exception for a Compelling Reason

Revision 24-5; Effective Nov. 1, 2024

In some situations, a person may request that tasks not be performed for them even though they have an impairment and may not be able to perform the task for themselves.

If a person has a compelling reason for not wanting any of the subtasks under the appropriate impairment score but only wants subtasks listed in a lower impairment score, the caseworker must document the person's request and allocate minutes in the minute range for the subtasks selected. The caseworker must document the reason, and no supervisory approval is required.

Example: The person scores a 2 on bathing. They need help with drying. However, when discussing subtasks, they state they would like standby assistance for safety and drawing of water, all under the impairment score of 1. They state their skin is very sensitive and they would not allow help with drying as they are afraid it would hurt them. The subtasks checked are all under the impairment score of 1, so ten minutes is allowed. Documentation is required to explain the variance. No supervisory approval is required.

Review Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, and Instructions for additional information.

2441.2 Exception for Assistance from a Caregiver or Other Agency

Revision 24-5; Effective Nov. 1, 2024

If a person has a caregiver or other agency performing part of a task and only subtasks with a lower impairment score are needed, the caseworker must document the person's request and allocate minutes in the minute range for the subtasks selected. The caseworker must document the reason and the part of the task the caregiver or other agency performs. No supervisory approval is required.

Example: The person scores a 2 for bathing, but only wants help laying out supplies and drawing water because their daughter provides all hands-on assistance with the bathing task. The task is marked P/C. The subtasks under the impairment score of 1 are checked, and ten minutes is allowed for the subtasks to be purchased. Documentation is required to explain the variance.

2441.3 Time Allocation for Companion Cases

Revision 24-5; Effective Nov. 1, 2024

For companion cases, base time allocated for general household tasks, including cleaning, shopping and meal preparation, on the companion minute range on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, not the individual range. Time is assigned per person based on the person's impairment score. Check the box(es) in the Total Minutes Per Week column for cleaning, meal preparation, and shopping to show that time is authorized for these tasks in the companion case. When there are more than two companions in the household, assign time based on the person's impairment score using the companion minute ranges.

When there are more than two people in the household, the caseworker continues to use the companion minute range based on the person's impairment score.

Example: On cleaning, Mr. Jones scores a 3, and Mrs. Jones scores a 1. Mrs. Jones can do some light housekeeping, but due to her husband's incapacity, he needs all cleaning tasks performed in his area. Mrs. Jones is allowed the maximum of 45 minutes under impairment score 1 in the companion range. Mr. Jones is allowed the maximum of 180 minutes under impairment score 3 in the companion range.

Review Form 2060 Instructions for more examples and guidance on companion cases.

2442 Calculation of Time to be Authorized

Revision 24-5; Effective Nov. 1, 2024

Use the following procedures to calculate the total amount of time needed each week.

  1. Multiply the number of minutes needed to conduct each task by the number of times the task will be performed each day to reach a daily total of minutes for each task. Times must be shown in five-minute increments. If necessary, round the time up to the next five-minute increment.

    Example: If a person needs to prepare meals twice a day and the preparation requires the maximum amount of time, multiply 30 minutes by two to reach a daily total of 60 minutes.
  2. Multiply the daily total of minutes for each task by the number of days per week the attendant will conduct that task. Times must be shown in five-minute increments and rounded up to the next five-minute increment if necessary.
  3. Add the required weekly minutes for all tasks and divide the total by 60 minutes to determine the weekly total in hours.
  4. Round the weekly number of hours to the next highest half unit to determine the number of units to be authorized. Example: If a person needs 7 hours and 10 minutes of service each week, authorize 7.5 units of service. The number of hours must be correctly rounded up for accurate authorization of services.

Use Form 2060, Needs Assessment Questionnaire and Task/Hour Guide to calculate the hours of service to be purchased. The correct number of hours must be authorized on Form 2101, Authorization for Community Care Services. Write comments in the Service Authorization System Online (SASO) Impairment Scoring" window in the Functional Wizard.

Tasks identified as needing to be purchased must be authorized on Form 2101. Tasks marked P in the Service Arrangement column of Form 2060 must also be marked on Form 2101. The meal preparation task may be marked P on Form 2060 and not marked on Form 2101 as long as the person is receiving home-delivered meals. A separate Form 2101 as authorizing meals is sent to the home-delivered meals agency.

2443 Balancing Incentive Program, Level II Assessment

Revision 24-3; Effective July 1, 2024

The Balancing Incentive Program (BIP) provides additional Federal Matching Assistance Percentage (FMAP) funds to states that initiate reforms to increase nursing home diversions and access to non-institutional long-term services and supports. As part of the effort to increase access to additional federal funds and meet BIP requirements, the Texas Health and Human Services Commission (HHSC) administers the Level II Assessment to all people requesting or receiving Primary Home Care (PHC), Community Attendant Services (CAS) and Day Activity and Health Services (DAHS) Title XIX. The Level II Assessment includes:

  • Part A of the Functional Assessment of Form 2060, Needs Assessment Questionnaire and Task/Hour Guide; and
  • Form 2060-B, Needs Assessment Addendum.

The BIP was created by the Affordable Care Act of 2010 and improves the state’s ability to serve more people by increasing access to non-institutional long-term services and supports. The BIP allows states to adhere to the integration mandate of the Americans with Disabilities Act (ADA), as required by the Olmstead decision.

The caseworker will complete the Level II Assessment, Form 2060-B, for initial assessments, annual reassessments, and for a significant change request for a new service.

For changes in services, the caseworker will complete:

  • Form 2060, Part A, Functional Assessment, if applicable;
  • Form 2060, Part B, Task/Hour Guide;
  • Form 2060, Part C, Task/Minute and Subtask Guide; and
  • Form 2060-B.

The following are examples of the forms that are completed when a request is made for a change in service:

Examples:

Example A – A person receiving CAS calls the caseworker requesting transportation help. The caseworker completes Form 2060, Part A and Form 2060-B. Only complete Form 2060, Part B and Part C, if applicable. In reviewing the required forms, the person only requests transportation and does not wish to have the service plan for their attendant care services changed. The caseworker will send a referral for transportation only. No other action is required.

Example B – A person receiving CAS calls the caseworker to request home-delivered meals. The caseworker completes Form 2060, Part A, and Form 2060-B and, if applicable, Form 2060 Part B and Part C. In reviewing the required forms, the caseworker places the person’s name on the Home-Delivered Meals Interest List and increases the time allotted for meal preparation for their attendant services. The caseworker completes the change per Section 2721.4, Revising the Service Plan, and Section 2721.6, Authorizing and Documenting Changes.

The caseworker determines if a referral is needed for HHSC services or non-HHSC services based on the information collected from Form 2060-B. The caseworker discusses and gets approval to make a referral with the person to non-HHSC services. Referrals may include:

  • behavioral health services;
  • supported employment or employment assistance;
  • transportation assistance;
  • help with instrumental activities of daily living, and
  • help for other medical conditions not previously addressed.

The caseworker documents the referrals made for the person in Section III of Form 2060-B, including any need for referrals identified but refused by the person. No data entry is required in the Service Authorization System Online (SASO) resulting from completing Form 2060-B only.

The person keeps the right to participate in their service plan development. They can also refuse all or part of any services and be informed of the likely consequences of such refusal, including referral to non-HHSC services.

Identified needs for referrals agreed to by the person are considered requests for information and referral. The caseworker makes use of applicable existing referral policy to help the person with the appropriate referral located in:

Referrals for behavioral health needs identified on Form 2060-B may be made to local mental health authorities. Use the local phone numbers available on the Mental Health and Substance Use page.

2500, Service Planning

2510 Service Plan Development

Revision 24-5; Effective Nov. 1, 2024

Program Standard: Caseworkers must develop service plans that accurately authorize appropriate services for people based on their needs, eligibility and priority level.

After completing Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, to assess the needs and unmet needs of the person, discuss service planning with the person or their family members. Consider all possible available resources through Community Care Services Eligibility (CCSE) services or other community resources. Evaluate if the person is interested in receiving Home-Delivered Meals (HDM), Emergency Response Services (ERS), or attending Day Activity and Health Services (DAHS), or other community centers. Review Form 2110, Community Care Intake, and address all services requested at the time of intake. Document any decisions made about the use of those services.

To the extent of their abilities, eligible people must be involved in the development of their service plans. Discuss service planning with a person or their caregivers during the initial visit. Whenever possible, complete service planning during the visit. If this is not possible, service planning may be completed after the visit and after financial eligibility has been determined.

The discussion with the person, and caregivers, should include the type of services that may be appropriate for purchase after the unmet need has been addressed and determined. To maintain self-sufficiency and a level of independence:

  1. Allow the person the opportunity to continue performing tasks they prefer to do themself, even though they may be challenging for them.
  2. Explain to the person that Texas Health and Human Services Commission (HHSC) programs are not designed to replace the care that caregivers now provide or are able and willing to provide over time.
  3. At the conclusion of the initial visit, ensure that the person fully understands precisely what services HHSC may provide, the limitations of HHSC services, and the importance of the existing caregiver arrangement in the development of a service plan.

The service plan should reflect consideration of all these factors:

  • person's existing problems that resulted in an application for CCSE services;
  • person's physical and mental health;
  • person's functional capacities for self-care;
  • person's need for, or availability of, self-help or adaptive devices;
  • existing caregivers and the specific amounts and types of assistance they give and can continue to give the person;
  • person's home environment and available community resources;
  • severity of the person's medical and physical problems and the level of risk the problems cause;
  • other HHSC services necessary to help the person maintain self-sufficiency, including referral to Adult Protective Services when appropriate;
  • additional services available in the person's community:
    • The 71st Texas Legislature passed Senate Bill 487 which requires, when appropriate to the person's needs, the use of services provided by other state agencies.
    • Review Appendix XV, Services Available from Other State Agencies.
  • services provided to other people in the household;
  • information secured from the person's practitioner, friends, or associates that may be necessary to develop a service plan suitable for the person's needs;
  • number of service units to be authorized and the rationale for the authorization;
  • dates that services are expected to begin; and
  • any special monitoring or case management procedures to be followed.

Document service planning information on:

Form 2110, Community Care Intake;
Form 2059-W, Summary of Individual's Need for Service Worksheet, which is entered in the Service Authorization System for Form 2059, Summary of Client's Need for Service;
Form 2101, Authorization for Community Care Services;
Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, which is entered in the Service Authorization System.

2511 Caregiver Arrangements

Revision 24-5; Effective Nov. 1, 2024

Discuss with the person and any family members or caregivers that Community Care Services Eligibility (CCSE) services are not designed to replace the care family members and other caregivers now provide or are able and willing to provide over time. Explain that the existing caregiver arrangement is very important to the development of a service plan. If possible, confirm with the caregivers that they are able and willing to perform the tasks listed on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, which are marked C for the caregiver.

Be sure the person and family members understand that CCSE services are to serve as something other than a supplement to income. Decisions about service plans cannot be based on the family's income or financial needs.

2512 Caregiver Support

Revision 24-5; Effective Nov. 1, 2024

Caregiver support is providing relief to a caregiver who provides most of the applicant's care or continual care for the applicant. This support is always provided by an attendant other than the applicant's regular caregiver. Caregiver support may be appropriate when the initial functional assessment results in no unmet need, but the caregiver needs relief. The paid attendant will provide some of the tasks that the caregiver has been performing to give relief.

Examples: Caregiving responsibilities prevent the person's caregiver from leaving the house to conduct personal business or do the family shopping. Or, the caregiver needs time away from their caregiving duties on a regular basis due to their health needs or for periods of rest due to the continual care.

Discuss with the caregiver how many days per week and what tasks may be needed to provide relief. Mark the appropriate items on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide with a P, and document on each task in the comments section when that support care is needed. Indicate on Form 2101, Authorization for Community Care Services, that the service plan is for caregiver support and list the caregiver as someone not to be hired. Support care may be temporary. If so, authorize it only for the time needed.

Note:  The local Area Agencies on Aging provide several services designed to support caregivers. Service availability varies by region. To find out if services are available in an area, provide the toll-free phone number 800-252-9240 to persons interested in potential services.

2513 Caregiver as the Paid Attendant

Revision 24-5; Effective Nov. 1, 2024

If the caregiver expresses an interest in being the paid attendant, inform them and the applicant that the caseworker cannot recommend to the provider who to hire as the paid attendant. It is the provider's responsibility to hire an attendant. Encourage people who want a specific person to be the attendant to discuss this with provider staff. The caseworker must explain to the potential attendant that they will be an employee of a home and community support services agency. They must be able to provide the tasks needed and work the complete specified schedule the provider and the applicant develop. Their performance will be monitored and evaluated by the provider and the caseworker.

The caseworker must also explain to the applicant and the caregiver that the tasks listed as C for caregiver under the service arrangement on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, must remain as caregiver tasks if the caregiver is hired as the paid attendant. Those tasks may not be purchased tasks if this caregiver is the paid attendant. If circumstances change and the attendant can no longer perform or is no longer willing to perform either the purchased tasks or the caregiver tasks, then the provider is requested to hire a new attendant for those tasks. The caregiver will be designated as someone not to be hired for those tasks on Form 2101, Authorization for Community Care Services.

In situations as described in Section 2433, Determining Unmet Need in the Service Arrangement Column, where the caregiver has recently quit employment to provide care, note the tasks the caregiver will continue to provide voluntarily and mark them as C in the service arrangement column of Form 2060. Other needed tasks may be purchased.

For ongoing cases, a caregiver who had been listed as working full time and quit a job to provide care for the person may also be considered as a potential attendant. The caseworker must get verification that the caregiver quit employment within 30 calendar days before the requested change. Any tasks previously identified as performed by the caregiver may not be purchased tasks.

2514 Who Cannot Be Hired as the Paid Attendant

Revision 24-5; Effective Nov. 1, 2024

The Texas Health and Human Services Commission (HHSC) is not responsible for selecting and hiring the person's paid attendant. The only role HHSC plays in the hiring process is notifying the provider when a particular person must not be hired.

Based on the following chart, if a person is identified as someone who must not be hired as a paid attendant, the caseworker documents this information in the Comments section on the initial and all later submissions of Form 2101, Authorization for Community Care Services. The caseworker enters Do Not Hire and the name of the person on the form. The following chart lists the persons who must not be hired and must be specified as Do Not Hire.

Do Not Hire:If the person:
Abused, Neglected, Exploited, as Substantiated by Adult Protective Serviceshas abused, neglected or exploited the person or others.
Parent of a Minor Childis the legal or foster parent of the minor child receiving Community Attendant Services (CAS). There is no prohibition against hiring the parent of an adult child to be the paid attendant.
Spouse in Primary Home Care (PHC) or CASis the spouse of the PHC or CAS person.
Unwilling Household Memberis not willing to help the person with any of the tasks the person needs.
Caregiver Supportcaregiver needs relief from providing giving care and the authorization for purchased services is based on caregiver support.
Person Designatedis a particular person the applicant or person does not want hired as the paid attendant.
Caregiver/Paid Attendant at Reassessmentis no longer able or willing to provide tasks previously designated as caregiver tasks. The caregiver may not be hired for those tasks. (Review Section 2664, Redetermination of Unmet Need.)

Beyond these limitations, the caseworker will not specify who cannot be hired as the paid attendant.

2520 Freedom of Choice

Revision 17-1; Effective March 15, 2017

 

2521 Freedom of Choice in Living Arrangements

Revision 24-5; Effective Nov. 1, 2024

The applicant has freedom of choice regarding their living arrangements. However, caseworkers are required to consider if the person's needs can be met in the environment chosen by the applicant.

Consider the person's ability to understand if the services the Texas Health and Human Services Commission (HHSC) can provide are enough to meet their needs. If the person has medical needs that cannot be addressed with personal care and housekeeping services, or if the environment poses a threat to health and safety, discuss these issues with the person and the responsible person.

Explain the limitations of Community Care Services Eligibility (CCSE) services and determine how the person's needs will be met. Explore the possibility of alternative living arrangements, if feasible and necessary. If the person insists on remaining in their current residence, even though their needs may not be met in that environment, assess their mental capacity for making an informed choice and if they understand the consequences of that choice. Review Section 2550, Identifying People at Risk, for additional information.

If they are capable of giving informed consent, respect their choice and develop a service plan accordingly. If they appear incapable of making an informed choice or if abuse, neglect, or exploitation is suspected, make a referral to Adult Protective Services.

2522 Service Delivery in Alternate Locations

Revision 24-5; Effective Nov. 1, 2024

It is acceptable to allow delivery of services meant for the home environment to be given in alternate locations. Hours diverted to provide services to the person in alternate locations may not be added back into the service plan. Example: A person's service authorization includes an hour each day for feeding or eating. The person will also need this help during a visit to their sister, who lives 20 miles away, which adds an hour to the time necessary to provide this help. The person opts to divert an hour allocated for laundry to feeding or eating to make the visit. This hour cannot be added back into the service plan to provide the amount of time required to do the laundry.

Do not anticipate the need for more hours based on the delivery of services outside the home and build that time into the service plan. It is also unacceptable to approve additional hours because the extra time expenditure does not allow the attendant enough time to do some other tasks. Hours authorized are based solely on services assumed to be provided in the home.

When people receive services outside the home, providers must document in the comments section of Form 3054, Service Delivery Record, the specific services provided and in which location. Documentation must also be available to substantiate the person who requested these services. The actual transportation, as well as the transportation cost, are the responsibility of the person.

2523 Freedom of Choice in Agency Selection

Revision 24-5; Effective Nov. 1, 2024

Once the applicant looks likely to meet the eligibility criteria for Community Care Services Eligibility (CCSE) services, offer the applicant the choice of selecting an agency contracted to deliver the requested service in the applicant's area. Either the applicant or the responsible person may make the selection. The selection must be documented on an agency choice list or other document in the case record.

If the applicant requests time to consider their choice or to consult with family members or other resources, leave the applicant a return envelope. You can also arrange to pick up the agency choice list when the decision is made.

If the applicant refuses to choose from all the contracted agencies in the service area, an agency may be selected for the applicant as a last resort. The selection is assigned from a regional agency rotation log, which must be maintained and kept up to date.

2530 Other Resource Services

Revision 24-3; Effective July 1, 2024

When determining unmet need, identify and examine the services of other agencies' that the person receives or is eligible to receive. This prevents service duplication and ensures all service resources are pursued. Refer to Appendix XV, Services Available from Other State Agencies, for information about services that may benefit the person. Document the use of other service resources on Form 2059-W, Summary of Individual's Need for Service Worksheet, Item 7.  Document information about other service resources in the Service Authorization System Online (SASO) Support Assisting Client window.

All other services available to the person must be considered and used before services are authorized by the Texas Health and Human Services Commission (HHSC).

2531 Veterans Affairs Aid and Attendance and Housebound Benefits

Revision 24-5; Effective Nov. 1, 2024

Some people receive Aid and Attendance (A&A) or housebound benefits (HB) from Veterans Affairs (VA). These benefits must be considered the primary source of funds to pay for in-home services.

HHSC has an information sharing program between HHSC, the Texas Veterans Commission (TVC), and the Veterans Land Board (VLB) to coordinate and collect information about the use and analysis among state agencies of data received from the Public Assistance Reporting Information System (PARIS) VA match. The PARIS system is a federal-state partnership that provides states with detailed information and data to help maintain program integrity and detect improper payments.

This information-sharing program helps identify HHSC recipients who may be eligible for veteran’s benefits. HHSC creates a file of active recipients in the Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF), and Medicaid programs. The file of active recipients is sent to the Defense Manpower Data Center (DMDC) on a quarterly basis for PARIS matching. DMDC returns a file of the matched recipients with veterans’ benefit information back to HHSC. This file is shared with the TVC and VLB to contact veterans who may be eligible for benefits or may be eligible for increased benefits and report those benefits back to HHSC.

HHSC will receive reports about A&A and HB that may affect the level of service currently authorized for personal attendant services (PAS).  HHSC will verify the information on any people currently receiving Community Attendant Services (CAS), Primary Home Care (PHC), Family Care (FC), Home and Community-based Services (HCS), Community Living Assistance and Support Services (CLASS), Deaf Blind with Multiple Disabilities (DBMD), Texas Home Living (TxHmL), or STAR+PLUS Home and Community Based Services (HCBS) programs. Since financial eligibility for CAS is determined by HHSC, any changes to eligibility status will be processed by HHSC.

Actions Required Upon Receipt of the Report

When the report is received, the region must distribute the information to the assigned caseworkers so they can contact the person and verify the change in VA benefits. For people receiving A&A or HB, the caseworker must discuss and document how the person is using the benefits. A list of some of the items or services that can be purchased using A&A or HB funds includes:

  • medical supplies;
  • medical equipment;
  • nursing services;
  • therapy;
  • skilled services;
  • medications; or
  • other medically necessary items.

If all the A&A or HB funds are being used to purchase items that help the person remain independent and in the community, the caseworker documents the information, and no funds are applied to the service plan.

The person may also use the funds to purchase:

  • PAS; or
  • home health aide services.

If the person is using the funds to purchase PAS or home health aide services, this must be considered when developing the plan of care. For FC, PHC, and CAS, note this on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, as services delivered by another agency. If the person can purchase all the services required, then there is no unmet need, and the person is not eligible for PAS. If the person can only purchase part of the necessary services, or if the funds are not used to purchase services, then the amount of the A&A or HB funds is applied to the purchase of attendant care per Form 2060 instructions.

If the funds are not used to purchase services that help the person remain independent and in the community, apply the funds to the purchase of non-skilled attendant care. Calculate the number of hours of non-skilled attendant care that could be paid for with the person's unused portion of A&A or HB. To do this, divide the unused portion of the monthly benefit by the maximum non-priority attendant care limit rate without regard to the service authorized. If the person meets the priority status criteria, use the maximum priority status attendant care limit rate. Subtract the resulting amount from the person's authorization. If the number of hours required by the person's unmet need is more than the benefits they can purchase, authorize the additional needed hours of PAS. Begin these calculations by using the actual number of hours required by the person's unmet need, even if this exceeds the maximum HHSC can purchase.

These procedures apply only to the purchase of PAS. Do not reduce the amount of other services because the person receives VA benefits.

Example: A person whose unmet need requires 20 hours per week of PHC receives A&A benefits. Dividing the amount of this person's A&A benefits by the current maximum attendant care limit rate yields 46 hours per month.

46 ÷ 4.33 = 10.6 hours per week

20 − 10.6 = 9.4 hours per week

This person may be authorized 9 1/2 hours per week.

Explain this procedure to the person. If the authorized hours cannot cover all of the purchased tasks that have been identified on Form 2060, then the person and caseworker should jointly decide which PAS tasks will be purchased and authorize only those tasks on Form 2101, Authorization for Community Care Services. Update the Service Arrangement Column of Form 2060 to match the tasks/hours authorized on Form 2101.

Reporting Requirements

Regional management will be required to report the savings generated by the application of VA funds. Example: A person requires 20 hours per week of PAS but is now receiving A&A funds. The A&A funds can purchase five hours per week, reducing the weekly service plan to 15 authorized hours per week. The cost of the five hours per week is reported as a savings for HHSC.

2532 Skilled Home Health Services

Revision 24-5; Effective Nov. 1, 2024

If a person is receiving or is eligible to receive Medicare or Medicaid skilled home health (SHH) attendant care services, the tasks provided or potentially provided must be considered as resources available to the person when determining unmet need. SHH is ordered for a person by their physician and is provided over a short period of time in conjunction with illness.

Use regional procedures to refer any applicant or person who requests or appears in need of SHH services.

It is possible to authorize other Community Care Services Eligibility (CCSE) services, including personal attendant services (PAS), at the same time SHH attendant care is being used. Both services may even be provided on the same day. If a person is receiving SHH attendant care, determine exactly which services are being delivered and ensure they will not be duplicated by any CCSE service that the person may need. If SHH provided attendant care on some but not all the days of a week, PAS may be authorized to provide attendant care on the other days, if needed. If SHH is providing all the personal care needed by the person but housekeeping services are needed, Family Care or Home-Delivered Meals may be suitable options to consider.

If SHH is providing only skilled nursing services by a registered nurse or licensed vocational nurse, the service would be unique from any other CCSE service that might be authorized and is not a consideration to determine unmet need. Consider how long SHH has been in use and how long it will continue as the CCSE service plan is developed with the person. If duplication of tasks would occur by authorizing a CCSE service, denial or a later revision to the service plan may be necessary.

2533 Hospice Services

Revision 24-3; Effective July 1, 2024

Medicaid recipients waive their rights to other programs with Medicaid services related to treatment of the terminal illness(es) when they elect the Medicaid Hospice Program. These waived services are limited to services also provided under Medicare. Recipients do not waive their rights to HHSC services unrelated to the treatment of the terminal illness(es). Therefore, participation of the person in a hospice program does not affect eligibility for Community Care Services Eligibility (CCSE) programs.

If a person chooses to receive hospice services and some of their needs will not be adequately met by the hospice agency, assess the person and authorize services for their remaining needs on the same basis as any other person.

Review Section 2745, People Who Need Hospice Services for more detailed information about the Hospice program.

2534 Mutually Exclusive Services

Revision 24-3; Effective July 1, 2024

Ask the person or family members if the person is receiving another HHSC service to determine:

  • unmet need for a particular Community Care Services Eligibility (CCSE) service; or
  • if a person can receive other HHSC services.

Check the Service Authorization System Online (SASO) and Texas Integrated Eligibility Redesign System (TIERS)  for services and refer to Appendix XX, Mutually Exclusive Services. Review Section 4000, Specific CCSE services.

2534.1 Services Through the Texas Home Living Waiver

Revision 24-5; Effective Nov. 1, 2024

Due to the limited services provided through the Texas Home Living (TxHmL) waiver, some Community Care Services Eligibility (CCSE) services are not mutually exclusive and can be received at the same time as Texas Home Living (TxHmL). Review Appendix XX, Mutually Exclusive Services.

Caseworkers must review the services received through TxHmL before authorizing CCSE services. This is to ensure there is no duplication of tasks and there is an unmet need for the service. People must meet the eligibility requirements for the specific CCSE service requested. The caseworker must document there is no duplication.

2534.2 Targeted Case Management and Other HHSC Services or the STAR+PLUS Program

Revision 18-1; Effective June 15, 2018

Local Authorities (LAs) provide service coordination through Targeted Case Management (TCM) to Individuals with Intellectual and Developmental Disabilities (IDD) in the HHSC LA priority population.

TCM authorizations are processed through the Service Authorization System Online (SASO). TCM services are identified in SASO as Service Group 14, Service Code 12A or 12C. TCM can be authorized along with Home and Community-based Services (HCS), Texas Home Living (TxHmL) or as a general revenue (GR) service.

TCM and Other HHSC Services

Other HHSC waiver services (excluding HCS and TxHmL) are mutually exclusive with TCM. An individual receiving any of the following waiver programs cannot receive TCM at the same time:

  • Community Living Assistance and Support Services (CLASS)
  • Deaf Blind with Multiple Disabilities (DBMD) Waiver

If an individual on TCM is applying for one of these waivers, then the SASO Service Codes 40, 40A and 60, for assessments, pre-assessments and prescriptions, are the only service codes allowed to overlap with TCM service authorizations.

Since the waiver programs identified above provide more comprehensive services to the individual, they will take precedence over TCM services in order to maximize the benefit to the individual. The HHSC case worker must contact the LA to coordinate closing TCM for the waiver service to begin. Individuals receiving the STAR+PLUS program may receive TCM. These services are not mutually exclusive.

The Program for All-Inclusive Care for the Elderly (PACE) is not a waiver program but an all-inclusive program. PACE is mutually exclusive with all other services including TCM. See Appendix XX, Mutually Exclusive Services

TCM and Other HHSC Services

Determining whether an individual who receives TCM services can receive other HHSC services, including Community Care Services Eligibility (CCSE) services, depends on whether he is receiving TCM services through HCS, TxHmL or as a GR service.

Once the case worker identifies an individual is receiving TCM, he or a regional designee must check the Client Assignment and REgistration (CARE) system to determine if the individual is receiving HCS or TxHmL. If the individual is receiving HCS or TxHmL, the case worker must refer to Appendix XX, to determine if the individual can receive other HHSC services, as some services are mutually exclusive and others are not.

If the individual is receiving HCS or TxHmL and the requested CCSE service is mutually exclusive, then the case worker will contact the individual to allow a choice of services and document the individual's choice. If the individual elects to continue receiving HCS or TxHmL, then the request for CCSE services is denied. If the individual elects to receive the CCSE service, then the case worker must contact the LA to coordinate closing services.

If the individual is not receiving HCS or TxHmL and is receiving TCM as a GR service, then he can receive other CCSE services.

2535 Involvement of Volunteer Resources

Revision 24-5; Effective Nov. 1, 2024

Volunteers may perform some services needed by people who are older and people with disabilities. When developing a person's service plan, consider if volunteers from community resources might meet some of the person's needs.

Volunteer help may include:

  • shopping and paying bills;
  • transportation;
  • phone reassurance;
  • friendly visits;
  • recreation activities, such as reading aloud, games, help with sewing, knitting, art, or other handwork; or
  • writing letters.

Some organizations may contribute group volunteer efforts to accomplish significant tasks for people with functional disabilities. These tasks might include:

  • clothing care and distribution;
  • yard work;
  • hauling trash;
  • cleaning windows;
  • critical home repair;
  • construction of ramps and assistive devices in the house;
  • provision of medical equipment or apparatus;
  • facilitation of support groups for caregivers; and
  • transportation for older people and people with disabilities who are shut ins.

Before finalizing a plan that involves volunteers, it's important to have a thorough discussion with the individual and their family or caregiver. If a person's needs are fully met through planned volunteer services, the case can be kept open as Case Management only. This means that the person's condition necessitates regular monitoring, but their needs are being met through volunteers. It's crucial to document all aspects of volunteer resources and their use.

2536 Program of All-Inclusive Care for the Elderly

Revision 18-1; Effective June 15, 2018

The Program of All-Inclusive Care for the Elderly (PACE) is an all-inclusive program that provides all required services for an individual enrolled in the program. 

PACE Referral

  • PACE services are available in designated areas of El Paso, Lubbock and Amarillo/Canyon.
  • Bienvivir Senior Health Services has two sites in El Paso that provide PACE services to participants. For referrals of potential participants, contact the Intake Department at Bienvivir Senior Health Services by telephone at 915-599-8812.
  • The Basics at Jan Werner has a site in Amarillo that provides PACE services to participants. For referrals of potential participants, contact The Basics at Jan Werner by telephone at 806-374-5516.

PACE Eligibility

To be eligible for PACE, the individual must:

  • be at least 55 years old;
  • be certified as nursing home eligible;
  • meet medical necessity criteria for nursing facility care;
  • choose PACE services; and
  • reside in a designated catchment area.

PACE Services

The PACE interdisciplinary team provides preventative, rehabilitative, curative and supportive services in day health centers, homes, hospitals and nursing homes. Required services include all Medicare and Medicaid covered services and any other services the multidisciplinary team identifies as a need.

The PACE Integrated Model of Care includes any health-related service needed, including but not limited to:

  • in-home services;
  • day health care;
  • primary care;
  • acute hospital care;
  • lab, x-ray and ambulance services;
  • skilled nursing facility care;
  • medical specialty services;
  • all in-patient and out-patient medical care;
  • specialty services such as dentistry and podiatry;
  • social services;
  • meals; and
  • transportation.

Texas Health and Human Services Commission (HHSC) intake screeners in the catchment areas must be aware of the PACE service and referral procedures for the service. Intake screeners must provide information about PACE to individuals during the intake and referral process when the individual requesting services is determined to be 55 years of age or older and resides in a PACE service area. Individuals in the PACE catchment areas may request services through the local HHSC intake office or through the PACE service site.

Since PACE is an all-inclusive program, it is mutually exclusive with all other HHSC programs and STAR+PLUS programs. See Appendix XX, Mutually Exclusive Services

2540 Priority Status

Revision 23-1; Effective March 1, 2023

A recipient priority status is assigned if an applicant or recipient cannot perform one or more of the following ‘priority tasks’ without hands-on help from another person:

  • feeding; 
  • eating;
  • toileting;
  • transfer; or
  • meal preparation. 

Assign priority status if at least one priority task is purchased and the recipient's:

  • functional score for that task is 3; and
  • support score for that task is 4.

Complete the service arrangement column on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide for each task where the recipient’s impairment score is 1, 2 or 3. Complete the support score column for each priority tasks where the recipient scores 3 and the service is being purchased.

If the attendant does not show up during a normally scheduled service shift, the recipient's health, safety or well-being may or may not be jeopardized. Always assess the potential impact on the recipient's health, safety or well-being when determining the effects of an attendant not providing service.

Do not designate a recipient as having priority status if the failure of the attendant to report to work would not result in any risk to the recipient's health, safety or well-being. If the recipient appears to be at risk (scores a 3 on a priority task with little or no caregiver support), document the reason(s) why a support score of 4 was not assigned.

In determining if health, safety or well-being is endangered, consider the worst result that might follow from the attendant not providing service.

Example: A recipient may have a friend who visits daily when they can, but the friend is regularly out of town on business. Determine the consequences of the attendant not showing up on a day when the recipient's friend is out of town.

Consider each recipient's condition and situation. One recipient may be able to miss a meal during a scheduled service shift because their caregiver will be home later to prepare the meal. Another recipient may not be able to miss a scheduled meal without risk to their health because of their nutritional needs or no caregiver to prepare the meal later. Contact the regional nurse if help is needed in assessing the risk that would result from an attendant not working during a scheduled shift.

Advise priority recipients of:

  • the importance of being available in their homes during the hours designated in the service plan; and 
  • to contact the provider in advance if the recipient knows they will not be at home during a normally scheduled shift. 

If information is received that a priority recipient will not be home, inform the provider.

Inform a priority recipient that the provider may monitor the attendant's work performance by making frequent calls or home visits. If a priority recipient objects to this increased monitoring of the attendant, the recipient has the option of withdrawing from priority status.

For priority cases, note in the comments section of Form 2101, Authorization for Community Care Services, this is a priority case. Use verbal referral procedures for new priority recipients negotiated with the provider.

Providers may not allow a service interruption for a recipient designated as priority status unless the:

  • service interruption is caused by suspension of services;
  • recipient is not at home when the attendant is scheduled to provide services; or
  • recipient requests that services not be provided on specific days.

The provider must notify CCSE staff within seven calendar days of a priority recipient not receiving scheduled services. This notification is for CCSE staff's information only. No response is required. Do not approve or disapprove service interruptions for priority recipients.

Recipients can refuse priority status. If a recipient refuses priority status, document in the case record the recipient's decision and the reason for it.

Because the unit rate for priority recipients is higher than the rate for non-priority, the maximum allowable service authorization is less for priority recipients. A priority recipient receiving the maximum hours per week may not be able to receive another Community Care Services Eligibility service for which they may be eligible. This could exceed the total expenditures allowed by the average daily nursing facility rate. A priority recipient can exercise the option to receive less than the maximum hours to receive another needed service or they can decline priority status. CCSE staff must give the recipient the choice and explain the options, including the advantages or disadvantages of each. Document the recipient's decision in the case record.

Related Policy 

Support Score and Establishing Priority, 2434
Negotiated Referrals, 2631
Priority Status Determination, 4624
Suspension of Services and Interdisciplinary Team Procedures, 4677
Cost Limit for Purchased Services, Appendix II

2550 Identifying People at Risk

Revision 24-5; Effective Nov.1, 2024

A person whose unmet medical or functional need constitutes a potential hazard to their health or safety may need individualized case management and monitoring procedures to minimize immediate dangers and to prevent deterioration of their condition. The caseworker may identify the unique problems of these people at the time of assessment and reassessment, or regional nurses may note them during utilization review visits. Provider staff may also alert the caseworker. Address these problems in the person's service plan and document the information on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, or on Form 2059-W, Summary of Individual's Need for Service Worksheet. This information is entered into Form 2059, Summary of Client's Need for Service, in the Service Authorization System. Consult with the unit supervisor and the regional nurse about threats to the person's health and safety and about unmet medical and functional need issues. Use a team approach to develop service and monitoring plans whenever necessary and feasible.

A critical level of risk exists when a person has specific medical, physical, and social characteristics that endanger their health and safety in current living arrangement. Factors that contribute to critical risk are the person's level of functional impairment, their medical condition, the quality and strength of their caregiver arrangement, and the physical and social conditions of their immediate environment.

The following characteristics are indicators of potential critical-risk situations. If two or more of these are present in a person or in their situation, the caseworker must decide if they should be handled as a person at risk.

  • The person has a score of 40 or higher on Form 2060.
  • No caregiver is available to provide needed assistance, or the person's caregiver may:
    • be unable or unwilling to provide the necessary care; or
    • exhibit abusive, neglectful behavior.
  • The person may not have sufficient mental clarity to make an informed choice and understand the consequences of that choice (scores of 2 or 3 on Item 23, Form 2060).
  • The person may be immobile or nonambulatory or may need total assistance with feeding, toileting, or medication and exhibit an inability to maintain their safety.
  • The person may have complex health problems that create the need for skilled nursing assistance with personal care tasks, specialized technical skills in daily management of personal care, or total assistance with several personal care tasks.
  • The person's home may need to be improved to provide a safe environment.

Document the critical-risk decision and the reasons for it on Form 2084, Risk Management Team Meeting Summary. 

2551 Caseworker Actions for People at Risk

Revision 24-5; Effective Nov. 1, 2024

The caseworker must discuss the person's needs and the critical conditions with the unit supervisor and any other person who may have identified the problems. The caseworker and unit supervisor determine if a risk management team meeting is necessary. If necessary, the caseworker will:

  • Organize and coordinate a team meeting. Include the provider supervisor, the unit supervisor and the regional nurse. If the situation indicates possible abuse, neglect, or exploitation, report this to Adult Protective Services staff at the Department of Family and Protective Services.
  • Discuss with the team the specific circumstances that place the person at risk, the options for dealing with those circumstances, and the person's capacity to consent. Determine if a team visit to the person's home is necessary.
  • Discuss and agree on how often and by whom monitoring contacts will be made. Document the monitoring plan per regional requirements.
  • Use information from team members and document the person’s circumstances or condition on Form 2084, Risk Management Team Meeting Summary. Have available team members sign the form. Keep the original in the case record and provide copies to team members.
  • Coordinate the team visit to the person's home, if necessary.  All team members may not need to attend.  Discuss with the person, their family, and caregivers:
    • specific circumstances that place the person at risk;
    • options for dealing with those circumstances;
    • the proposed monitoring plan; and
    • the limitations of Community Care Services Eligibility (CCSE) services.
  • Discuss Attachment 2307-A, Family Care, Community Attendant Services and Primary Home Care Rights and Responsibilities, with the person, their family members, and caregivers. Make sure they understand the proposed service plan and the limitations of CCSE services. Review Form 2307, Rights and Responsibilities, with the person, family member or caregiver. The caseworker must sign the form and file it in the case record.
  • Monitor the person per the monitoring plan, documenting contacts until the circumstances or problems that caused the person to be at critical risk are as stabilized as possible or until the person's circumstances or degree of risk changes. Coordinate monitoring contacts with provider staff and with the regional nurse.
  • Conduct functional reassessments every 12 months, or more often if needed, depending on the person's situation or as indicated in the monitoring plan.

If the team members disagree about whether a person is at risk, the person who first identified the critical risk indicators should document the following:

  • person's situation that puts them at risk;
  • notification of other appropriate parties, including the caseworker's supervisor; and
  • responses to the notification.

If service plan disagreements cannot be resolved through team discussions, the unit supervisor consults with the lead regional nurse and, if necessary, the program director. Any difficulties with providers that cannot be resolved through discussion should be reported to the contract manager. If the problem cannot be resolved during the discussion process, the regional director will make the final decision.

If, during the service planning process, staff become aware the person's mental and physical health needs are not likely to be adequately met by authorized HHSC services, inform the person and their family about alternative living arrangements and nursing home care, if appropriate. Document this conference and the person's response on Form 2084. The person and their family decide if they are to remain in their present living arrangement, using the available services. The person is free to refuse any or all services offered.

2600, Authorizing and Reassessing Services

2610 Application Processing and Notification

Revision 24-3; Effective July 1, 2024

Eligibility for CCSE services for income-eligible applicants is determined within 30 calendar days after a signed application is received. For categorically eligible applicants, the eligibility determination process begins within 30 calendar days after the person’s assessment with CCSE staff. This process involves a thorough assessment of the applicant's circumstances and needs.

No further action is necessary if the person withdraws the request for services, before the assessment is started or completed, an application is received, or a face-to-face home visit is made.

Related Policy

26 Texas Administrative Code Section 271.151(d) 
Categorical Eligibility, 2341.3 
Income and Income Eligibles, 3310

2611 Processing Time Frames

Revision 24-5; Effective Nov. 1, 2024

Program Standard: The caseworker is required to determine eligibility for Community Care Services Eligibility (CCSE) services for income-eligible applicants as soon as possible, but within 30 calendar days after a signed application is received. The caseworker must determine eligibility for categorically eligible applicants as quickly as possible but within 30 calendar days after either the person's assessment or face-to-face contact with the caseworker, whichever occurs first.

Note: Eligibility for Home Delivered Meals (HDM), which does not require financial determination, must be determined within 30 calendar days from their assessment date.

This standard is applied to all applications, except for Community Attendant Services (CAS), using the date shown as the Date Eligibility Rules Processed  on the Service Authorization System Online Wizards (SASOW) Form 2064, Eligibility Worksheet as the end point of measurement. The 30 calendar day processing deadline cannot be used to delay a decision if all information is available before the 30th calendar day.

Proceed with the eligibility determination process if the person fails to cooperate but has received facility-initiated Day Activity and Health Services (DAHS) when the person is receiving Medicaid benefits.  Review the procedures in Section 4231.2, Intake Response.

2611.1 Processing Time Frames for Community Attendant Services

Revision 24-5; Effective Nov. 1, 2024

Applications for Community Attendant Services (CAS) must be referred to Medicaid for the Elderly and People with Disabilities (MEPD) staff for a financial eligibility determination. The MEPD process may delay Community Care Services Eligibility (CCSE) certification beyond the 30 calendar day time frame.

MEPD may notify the Texas Health and Human Services Commission (HHSC) caseworker of the eligibility decision through the MEPD to HHS Communication Tool.  If a decision is not received, the HHSC staff person must check the Texas Integrated and Eligibility Redesign System (TIERS) for an MEPD eligibility decision on or before the 25th calendar day from the application date and perform weekly checks until the financial eligibility decision is received. The TIERS checks must be documented.

When the financial eligibility decision notification is received either through TIERS or the MEPD to HHS Communication Tool, the caseworker has seven business days to:

  • complete data entry in the Service Authorization System Online Wizards (SASOW); and
  • send the referral packet to the Home and Community Support Services Agency (HCSSA) to begin pre-initiation activities.

The seven business days are measured from the date HHSC receives the eligibility decision from MEPD or the date eligibility is verified through TIERS. The caseworker must print a copy of the financial eligibility notice or TIERS screen and file it in the case record.

The HHSC caseworker must advise MEPD only if the applicant is not approved for CAS,  that is, no practitioner’s statement or other circumstances preventing services deliver. In this circumstance, the caseworker must send Form H1746-A, MEPD Referral Cover Sheet, to MEPD within two business days of determining the person is not eligible for CAS, advising that the applicant has not met the functional eligibility requirements. Form H1746-A is sent to MEPD at the same time Form 2065-A, Notification of Community Care Services, is sent to the person notifying them of CAS ineligibility.

The caseworker is not required to notify MEPD when CAS services are authorized.

Review Section 4653, Referral to the Provider, and Section 4660, Service Authorization, for more procedures for authorizing CAS services.

Caseworkers always have seven business days after confirmation of MEPD eligibility to send the referral to the provider. This applies even when verification of MEPD certification is received near the end of the 30 calendar day period allowed for completing CCSE applications.

2612 Notification of Eligibility Decision

Revision 24-5; Effective Nov. 1, 2024

An applicant or person certified for one Community Care Services Eligibility (CCSE) service but determined ineligible for another must be notified in writing of both decisions. An applicant or person certified for Personal Attendant Services (PAS) or Home-Delivered Meals (HDM) must also be notified in writing of the service units per week they are eligible to receive. If certified for Day Activity and Health Services (DAHS), the applicant or person must be notified in writing of the number of days per week the DAHS authorization covers. The written notice for all services must contain the caseworker's name, phone number and appeal procedures.

When notifying the applicant of eligibility, specify on Form 2065-A, Notification of Community Care Services:

  • the CCSE services for which the applicant is eligible or ineligible; and
  • if determined eligible:
    • the number of hours of services the applicant is authorized to receive or the number of days or half days the applicant is authorized to attend a DAHS facility;
    • if applicable, that the Family Care, Community Attendant Services or Primary Home Care applicant is eligible for priority status; and
    • the initial and ongoing copayments the person is to pay to the Residential Care facility.

The caseworker may notify a person verbally of continued eligibility if the person continues to qualify for the same service(s) and the number of hours or units of service remains the same.

Review Section 2662, Redetermination of Financial Eligibility, and Section 2660, Reassessments and Recertification Procedures, for time limits that apply when eligibility is redetermined.

2613 Case Record Documentation

Revision 24-4; Effective Sept. 1, 2024

To document the eligibility decision, the applicant’s case record must contain dated copies from Service Authorization System Online (SASO) of the following forms:

  • Form 2064, Eligibility Worksheet, except if;
    • the application is denied before a financial eligibility determination is made; and
  • Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, except if the;
    • applicant requested only Day Activity and Health Services (DAHS), which does not require a Form 2060 score;
    • applicant withdrew the application before the caseworker completed Form 2060;
    • application is denied for a reason other than:
      • no unmet need;
      • insufficient functional impairment; or
      • low hours for Family Care or Primary Home Care.

Note: Ensure each person enrolled in a Title XX program who is not categorically financially eligible receives a privacy notice, Form 0401, Notice of Privacy Practices or Form 0403, Explanation to Health Information Privacy Rights, as appropriate.

Related Policy

Privacy Notice, 1147

2620 Service Authorizations

Revision 24-5; Effective Nov. 1, 2024

After developing the service plan with an eligible person, enter information in the Service Authorization System Online Wizards (SASOW) to authorize services.

Service plans may include one or more purchased services. If authorizing more than one service, ensure the tasks are not duplicative, and the service combinations are within the allowable costs specified in Appendix II, Cost Limit for Purchased Services.

Example: Before authorizing ten units of Day Activity and Health Services (DAHS) per week for a person who will also be receiving an in-home service, determine if it is feasible for the person to take part in DAHS five full days per week.

Based on the urgency of the person’s need, negotiate with the provider for the earliest possible date that services can begin. Remember that services can and may need to start on the weekend if a person is discharging from a hospital or other institution on a Friday afternoon and needs services immediately. Enter the negotiated beginning date of coverage.

Use the comments section of Form 2101, Authorization for Community Care Services, to give specific instructions to the provider about the person’s service arrangement. These include the number of days the person requests services, specific service schedules required or strongly preferred by the person, specific instructions about unique personal problems or the person’s home, or information about people who should not be hired as the paid attendant.

For all personal attendant services (PAS), send the provider the initial packet, which must include a cover sheet, the Long-term Care Services Intake System (NTK) generated Form 2110, Community Care Intake, and a copy of the following SASOW generated forms:

  • Form 2059, Summary of Client’s Need for Service;
  • Provider Referral Supplement;
  • Form 2060, Needs Assessment Questionnaire and Task/Hour Guide;
  • Task/Hour Guide; and
  • Form 2101, Authorization for Community Care Services.

Note: In the SASOW, the following forms are generated as two forms:

  • Form 2059 is generated as Form 2059 and the Provider Referral Supplement.
  • Form 2060 is generated as Form 2060 and the Task/Hour Guide.

For Family Care, Form 2101 is an authorization to begin services.

For CAS and PHC, Form 2101 is a referral, and authorization for services is left pending receipt of Form 3052, Practitioner’s Statement of Medical Need.

Providers must follow the instructions on Form 2101. If a provider does not, try to resolve the problem through discussion with the provider’s supervisors. If this fails, document and report the issue to your supervisor and follow the procedures specified in Section 2700, Service Monitoring, Changes, and Transfers.

Related Policy

Content of Referral Packets, Appendix XIII

2630 Referrals to the Provider

Revision 17-1; Effective March 15, 2017

Refer to Section 4000, Specific CCSE Services, for specific procedures for each service for sending referrals to providers. See Appendix XIII, Content of Referral Packets, for referral-packet contents sent to providers for each service.

2631 Negotiated Referrals

Revision 24-5; Effective Nov. 1, 2024

Program Standard: People must be referred by the next business day after the day the person is visited and it is determined that a negotiated verbal referral is necessary. Form 2101, Authorization for Community Care Services, must be sent within five business days from the date the person was determined eligible for a negotiated verbal referral. Use the comment section of the form to document verbal referrals, dates and other relevant information. The caseworker must document the date Form 2101 was sent to the provider or include the fax confirmation.

Regardless of the response criteria established for the applicant at intake, the caseworker must reassess the person's need for service initiation during the assessment process. Specifically, assess the continued provision of any assistance with the person's personal care needs by people or other providers.

If it is determined that the person's unmet needs for personal care are, or will be, such that services must begin sooner than the time usually required when using the routine written referral process, contact the provider and negotiate a start date per the person's need for service initiation. The need for a verbal referral will vary from person to person. Consult with the unit supervisor if a person's particular circumstances are such that it is uncertain whether to use the negotiated referral process.

2632 Routine Referrals

Revision 24-5; Effective Nov. 1, 2024

Program Standard: For applicants who do not require negotiated referrals, authorize services by sending Form 2101, Authorization for Community Care Services, within five business days from the date the applicant is determined eligible. The caseworker must document date Form 2101 was sent to the provider or include the fax confirmation.

For services other than Day Activity and Health Services (DAHS), Community Attendant Services (CAS) and Primary Home Care (PHC), the provider must return Form 2101 by the 21st calendar day from the date of the referral. If Form 2101 or some other kind of notification is not received, contact the provider to find out the reason for the delay and the status of the referral.

If the provider is unable or fails to provide services within the 21-calendar day time frame, the caseworker may contact the person to discuss a possible referral to a different provider agency. 

Review Section 4000, Specific CCSE Services for special referral procedures for PHC, CAS and DAHS.

2640 Provider Requirements for Hiring a Paid Attendant

Revision 24-5; Effective Nov. 1, 2024

Criminal background checks are required for all facilities and service providers who provide care to older people and people with disabilities. Except in emergency situations, providers are required to get a criminal history check before offering permanent employment to unlicensed employees having direct contact with recipients who receive:

  • Day Activity and Health Services;
  • Residential Care;
  • Primary Home Care;
  • Community Attendant Services;
  • Family Care;
  • Adult Foster Care; or
  • Consumer Managed Personal Attendant Services.

A person must be barred from employment if they have been convicted of a criminal offense where an administrative review is not available. A person may request an administrative review for some criminal offenses that could bar employment.

If asked by anyone, including the recipient, about the results of the criminal history check, explain that:

  • all providers must conduct criminal history checks on attendants;
  • the Texas Health and Human Services Commission (HHSC) is monitoring compliance with the law; and
  • confidentiality requirements prevent the sharing of information obtained because of a criminal history check with anyone except the employee.

2650 Changes in Service Plans

Revision 17-1; Effective March 15, 2017

2651 Disagreements about Service Plans

Revision 24-5; Effective Nov. 1, 2024

If a disagreement arises between provider staff and Texas Health and Human Services Commission (HHSC) staff about a person's service plan, resolve the problem through discussion and negotiation. Use an interdisciplinary team meeting (IDT) if necessary. Ensure that services are not delayed unnecessarily because of these disagreements.

HHSC regional nurses make final decisions in disagreements with providers about a person's medical need for Community Attendant Services and Day Activity and Health Services.

In all other cases, the Community Care Services Eligibility (CCSE) supervisor attempts to resolve the disagreement with the provider's supervisor. If the supervisory staff of both providers cannot resolve the disagreement, the CCSE program manager resolves the disagreement.

2652 Changing the Service Schedule Between Reassessments

Revision 24-5; Effective Nov. 1, 2024

Use the chart below to determine which changes must be included on Form 2101, Authorization for Community Care Services, if a schedule change results in a change in hours or priority status.

Type of RecipientSpecific Instructions
Ongoing Primary Home Care or Community Attendant Services or Family Care

Specific Instructions

Specify the effective date as the beginning date of the service plan change on Form 2101, Item 4. If the change results in:

  • an increase in hours, the Begin date on Form 2101 must be seven calendar days from the Form 2101 date, unless another date is negotiated; or
  • a decrease in hours, the Begin date on Form 2101 must be at least 12 calendar days from the Form 2101 date.

    Note: For a decrease in hours, the Begin date on Form 2101 must match the effective date on Form 2065-A, Notification of Community Care Services.
Community Attendant Services

Specific Instructions

If a change is being conducted with an annual reassessment, enter the Begin date shown below and leave the authorization Pending. The regional nurse authorizes Form 2101.

If a decrease in service is being implemented between assessment periods, the Begin date should be 12 calendar days in the future to allow advance notice of the reduction in service. The Begin date must match the effective date on Form 2065-A.

For an increase in hours, the Begin date should be dated seven calendar days in the future. This allows the provider time to implement the change, unless a different date has been negotiated.

Family Care and Family Care transfer case

For a decrease in hours the Begin date should be 12 calendar days in the future to allow advance notice of the reduction in service.

For an increase in hours, the Begin date should be dated seven calendar days in the future to allow the provider time to implement the change, unless a different date has been negotiated.

Primary Home Care, Community Attendant Services or Family Care

Transfer to Priority Status.

Use verbal referral procedures for new priority recipients.

For decreases if the last day of any period is a Saturday, Sunday or legal holiday, the period is extended to include the next day that is not a Saturday, Sunday or legal holiday. Skeleton crew days are not legal holidays. Legal holidays are days when the agency is closed.

Example: Form 2065A is being sent Aug. 5 to notify a person of a decrease in hours. The 12th day of adverse action would be Aug. 17, which falls on a Saturday. The effective date on Form 2065A and Form 2101 would be Aug. 20 as the person has through the end of the business day, Aug. 19, to file an appeal.

Complete Form 2067, Case Information, for personal attendant services for all other changes not related to a change in hours.

Related Policy

Form 2101 Coverage Dates for Title XIX Services, Appendix XXIII

2653 Provider Flexibility

Revision 24-5; Effective Nov. 1, 2024

Providers are, should follow instructions given on Form 2101, Authorization for Community Care Services, as much as possible. There may be times when changes in tasks or schedules are necessary to meet the person's needs. In these situations, the provider doesn’t need to notify the caseworker as long as the units delivered and billed for a calendar month are at most 4.33 times the adjusted weekly hours identified on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide.

Example: A person who regularly receives 15 hours of service per week is sick for two days and declines services due to illness. During those two days, a total of five hours of personal care services would have been delivered had the person been able to receive services. Because the person may have an increased need for services following the illness, those five hours may be made up if it would be to the benefit of the person. Because the number of hours delivered does not exceed the number of hours authorized, the provider does not need to notify the caseworker.

This ongoing flexibility is to allow services to meet the person's needs, considering their desires and changes in their condition. The flexibility is not intended to be for the convenience of the provider or to be applied retroactively to justify an attendant absence or interruption of services.

If a provider makes changes to tasks or schedules inappropriately or against the person's wishes, try to resolve the issue through discussions with a provider supervisor. If this fails, report the issue to the caseworker's supervisor and follow procedures specified in Section 2700, Service Monitoring, Changes and Transfers.

2660 Reassessments and Recertification Procedures

Revision 24-5; Effective Nov. 1, 2024

Conduct reassessments within:

  • 24 months of the previous financial redetermination; and
  • 12 months of the previous functional assessment.

Annual reassessments are required for all CCSE services. Review Section 2663.1, Annual Home Visit Required for People Receiving PAS, and Section 2663.2, Determining When a Home Visit is Necessary for Other Services, to determine if a home visit is required for the reassessment.

When the reassessment is conducted in the person's home, the caseworker must schedule the visit with the person or their authorized representative at a time that is convenient to the person. Schedule the appointment by phone or in writing using Form 2068, Application, Redetermination or Monitoring for Community Care Services. If the appointment cannot be kept for some reason, inform the person or their authorized representative in advance that the appointment needs to be rescheduled. Only visit the person with advance notice of the visit.

During the reassessment, the caseworker must:

  • redetermine functional eligibility on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, as required by the specific program;
  • redetermine unmet need, as outlined in Section 2433, Determining Unmet Need in the Service Arrangement Column;
  • review Form 2307, Rights and Responsibilities and all applicable attachments;
  • present the Consumer Directed Services (CDS) option and review Form 1581, Consumer Directed Services (CDS) Option Overview. Review Section 6333.1, Authorizing CDS for Ongoing People and Section 6333.2 Transfers and Consumer Directed Services (CDS); and
  • present Form H0025, HHSC Application for Voter Registration, and offer the opportunity to register to vote.

To comply with the National Voter Registration Act of 1993, the person must be offered the opportunity to register to vote at the time of application and at each annual redetermination. Help any person who requests assistance in completing Form H0025, and review Form H0025 for completeness in the person's presence. The person may:

  • mail Form H0025; or
  • return the form to the caseworker's office for appropriate mailing to the county registrar's office.

2661 Person Unavailable for Reassessment

Revision 24-5; Effective Nov. 1, 2024

In some situations, the caseworker uses their judgment to determine how long a case should remain open when the person is unavailable for a reassessment. Generally, if the person continues to be unavailable for more than 30 calendar days, it should be determined if the unavailability is temporary. If a person is repeatedly unavailable after an appointment has been scheduled, refer to the procedures in Section 2830, Refusal to Comply with Service Delivery Provisions. If the person is unavailable because of temporary nursing home admission, use the time limits and procedures in Section 2822, Service Suspension by Caseworkers.

If a caseworker contacts an applicant or person to schedule or complete a home visit or reassessment and the person states they are unavailable, the caseworker must document the contact and the reason for the delay of the home visit or reassessment. The caseworker should schedule a future date for the home visit or reassessment when the person will be available. If unable to schedule the visit for a future date, the caseworker must contact the person at least weekly until the home visit or reassessment can be completed. This documentation will be considered as an acceptable reason for the delaying a required home visit or reassessment.

2661.1 Delay in Home Visits Due to the Person's Illness

Revision 24-5; Effective Nov. 1, 2024

While required home visits must be completed on a timely basis, due to the increase in transmittable diseases in the general population, there may be circumstances that could place staff at risk for contracting contagious illnesses.

To ensure the health and safety of staff members who could encounter people reporting a contagious illness, caseworkers may delay home visits under the following circumstances.

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

2662 Redetermination of Financial Eligibility

Revision 24-5; Effective Nov. 1, 2024

Program Standard: The caseworker must redetermine financial eligibility within 24 months of the previous determination of financial eligibility.

The financial reassessment must be completed by the last day of the 24th calendar month from the previous financial redetermination. To redetermine financial eligibility for income-eligible people, use the policies and procedures in Section 3000, Eligibility for Services. The caseworker must:

  • compare income and resources reported this year with what was previously reported;
  • discuss with the person any discrepancies between the two; and
  • verify the existence and amounts of new income or resources if these additional assets bring the person within proximity to eligibility limits.

Caseworkers must be diligent in ensuring that people receiving personal attendant services (PAS) are served by Title XIX PAS when possible. If the financial situation of an ongoing Family Care (FC) person has changed in a way that might make them eligible for Community Attendant Services (CAS), a referral should be made to Medicaid for the Elderly and People with Disabilities (MEPD) at the next financial reassessment.

Example: An FC person was denied CAS eligibility at the time of application because of resources that exceeded the $2,000 eligibility limit. However, the person now reports a total of $1,200 in resources and other CAS eligibility, such as a need for a personal care task, are met. At the financial reassessment, a referral to MEPD must be made.

2662.1 Financial Reassessments for Community Attendant Services (CAS)

Revision 21-3; Effective September 1, 2021

MEPD staff must redetermine financial eligibility for CAS annually.

Renewal packets are mailed 60-90 days prior to the annual renewal date. Complete and return Form H1200, Application for Assistance – Your Texas Benefits, along with any required verification documents, within 30 days. If Form H1200 and the required verification are not received by the due date, benefits will be denied.

During regular monitoring visits, remind CAS recipients of the importance of completing and returning the renewal form within the 30-day timeframe so they can continue to receive services. Ensure recipients are aware they can complete an annual renewal online through YourTexasBenefits.com  or over the phone by calling 211.

Some CAS recipients may receive Form H1200-SR, Streamlined Redetermination for Medicaid for the Elderly and People with Disabilities, instead of Form H1200. The cover letter for Form H1200-SR will advise the recipient that no action is needed if there are no changes to the reported information and the renewal form does not need to be returned.

Recipients who are receiving CAS and SNAP or TANF benefits will also receive Form H1010, Texas Works Application for Assistance - Your Texas Benefits. Remind CAS recipients that, in addition to completing Form H1200 to renew CAS benefits, Form H1010 must be completed and returned to continue to receive SNAP or TANF benefits.

If verification of ongoing functional eligibility is requested by MEPD at the annual redetermination, send a copy of the Service Authorization System Online (SASO) Service Authorization screenshot to show the recipient remains active on CAS. Use Form H1746-A, MEPD Referral Cover Sheet, to fax the information to the Document Processing Center (DPC).

Related Policy

Guidelines for Completing Form H1746-A. MEPD Referral Cover Sheet, Appendix V

2663 Reassessment of Functional Need

Revision 24-5; Effective Nov.1, 2024

Program Standard: The caseworker reassesses the person's functional needs within 12 months of the previous assessment. The functional assessment must be completed by the last day of the 12th calendar month from the previous functional assessment.

To reassess functional needs, use the policies and procedures in Section 2430, Functional Assessment, and in the instructions for Form 2060, Needs Assessment Questionnaire and Task/Hour Guide.

  • For services requiring a functional needs Form 2060 score for eligibility, the caseworker must complete or update the score in Part A of Form 2060 at each annual reassessment.
  • For people who receive Day Activity and Health Services (DAHS) or Consumer Managed Personal Attendant Services (CMPAS) as the only service, a Form 2060 score is not required.
  • For Family Care (FC), Community Attendant Services (CAS), and Primary Home Care (PHC), the caseworker must review Part B and Part C of Form 2060 at least annually during the interview with the person.

2663.1 Annual Home Visit Required for People Receiving PAS

Revision 24-5; Effective Nov. 1, 2024

Program Standard: A home visit must be conducted with all people receiving Community Attendant Services (CAS) for all annual reassessments and 90- day monitoring contacts. A home visit must be conducted with all people receiving Primary Home Care (PHC) and Family Care (FC) at least once every 24 months at the same time the financial redetermination is conducted.

During the home visit, the caseworker provides oversight of the person's health and safety. The caseworker must evaluate the person's ability to cope with the activities of everyday living in the home environment and identify when changes to the service plan or the addition of other services provided by the Texas Health and Human Services Commission (HHSC) may be of benefit.

For CAS, it is recommended the caseworker complete the annual functional reassessment during the last 90-day monitor for the year before the annual being due. If the annual functional reassessment is not completed during the last 90-day monitoring visit prior to the annual being due, then an additional home visit is required to complete the reassessment. An exception to having to make a home visit is when Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, has been completed within the last 60 days due to an interim change, the caseworker may conduct the annual reassessment by telephone.

For all CCSE services, if a person requests a change at the annual reassessment, the change must be processed within five business days or by the annual reassessment due date, whichever is earlier.

For CAS, Form 2101, Authorization for Community Care Services, will continue to be sent within five business days of the home visit due to the regional nurse approval requirements for the program.

All annual reassessments must be recorded on Form 2314, Satisfaction and Service Monitoring, and in the Service Authorization System Online Wizards (SASOW). It must include the person as the primary contact and the location as a home visit.

2663.2 Determining When a Home Visit is Necessary for Other Services

Revision 24-5; Effective Nov. 1, 2024

For services other than Community Attendant Services, determine if the reassessment should be done in a face-to-face home visit or by phone interview based on the service received and the person's circumstances. Review Section 4000, Specific CCSE Services, for home visit requirements for each specific service.

Individual circumstances that may include the need for a face-to-face reassessment include but are not limited to:

  • a service other than Emergency Response Services or Home-Delivered Meals is being added to the service plan;
  • people with no phone or who cannot communicate by phone because of cognitive or physical impairments or lack a knowledgeable source to contact;
  • Community Care Services Eligibility (CCSE) recipients who are receiving services from Adult Protective Services (APS) or have a history of self-neglect;
  • people who have experienced multiple changes in a short time, such as significant changes in health, living arrangements, or caregiver arrangements, and the caseworker is unable to get an accurate assessment that reflects all the changes by phone;
  • case transfers to caseworkers or newly hired caseworkers unless the losing and gaining caseworkers discuss and agree on the person's condition;
  • people with weak, unreliable, or no caregiver support systems;
  • people who have a history of refusal to comply with service provisions;
  • people whose health and safety are at risk; or
  • people who choose to live in a home with dilapidated, unsanitary, or hazardous living conditions.

Caseworker circumstances may warrant that a home visit be made, such as caseworker trainees assigned to a caseload.

2664 Redetermination of Unmet Need

Revision 24-5; Effective Nov. 1, 2024

The unmet need policy applies to ongoing cases and to applications. At each reassessment, the caseworker must evaluate if the Community Care Services Eligibility (CCSE) services already being purchased are meeting needs that would go unmet unless services were purchased. During the annual functional assessment or for each request for a change in service plan or hours, review each task on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide.

In the Service Arrangement column, determine if needs are being met through other sources or if the person continues to have a need for the task to be purchased. If there are no tasks to be purchased, the person no longer has an unmet need and is no longer eligible. If unmet need exists, continue with the development of an appropriate service plan.

In situations where the person's caregiver also serves as the paid attendant, carefully review the tasks marked C on the Service Arrangement Column on the previous Form 2060. These are the tasks that the caregiver agreed to perform voluntarily at the last assessment. These tasks may not be purchased. If the caregiver states that they are no longer able or willing to provide help with the tasks, then advise the caregiver that the provider will be notified to hire a new paid attendant for those tasks. Document any changes in caregivers or caregiver tasks on Form 2060 and Form 2059-W, Summary of Individual's Need for Service Worksheet. The information on Form 2059-W is entered in the Service Authorization System Online Wizards (SASOW) for Form 2059, Summary of Client's Need for Service.

In reassessment decisions, the policy about duplicate services must be applied.

2670 Notifications at Reassessment

Revision 24-5; Effective Nov. 1, 2024

The person must meet the CCSE eligibility requirements at the time of recertification of financial eligibility and reassessment of functional needs to continue receiving services.

Program Standard - Notify the person in writing, using Form 2065-A, Notification of Community Care Services, of changes in their service plan, to include:

  • addition of service(s);
  • increase in hours;
  • decrease in copayment; or
  • loss of priority status based on the person’s request.

Form 2065-A must be sent within two workdays of the decision if the change involves:

  • denial of priority status if the applicant requests it;
  • an increase in units;
  • a decrease in the copayment; or
  • adding a new service.

Related Policy

26 Texas Administrative Code Section 271.153

2680 Recertification

Revision 21-4; Effective December 1, 2021

When the reassessment is complete, send the following forms to the provider:

  • Form 2101, Authorization for Community Care Services, for all Day Activity and Health Services, Primary Home Care, Home-Delivered Meals, Family Care and Residential Care cases when there is a change in the service plan.
  • Form 2101, for all Community Attendant Services (CAS) cases, even if there is not a change in the service plan.
  • Form 2065-A, Notification of Community Care Services, for all cases when there is a change in the service plan. It is not necessary to send notification if the only change is a transfer from one provider to another.

For Adult Foster Care (AFC), send the following:

  • Form 2065-A, for all cases when there is a change in the service plan. It is not necessary to send notification if the only change is a transfer from one provider to another.
  • Form 2101, for all cases even if there is not a change.
  • Form 2327, Individual/Member and Provider Agreement, update as needed.
  • Form 2330, Assessment and Service Plan Approval for Adult Foster Care, even if there is not a change.
  • Attachment 2307-F, AFC Rights and Responsibilities, only if the recipient has moved to another home.

Related Policy

Content of Referral Packets, Appendix XIII
Effective Dates, 2811

2700, Service Monitoring, Changes and Transfers

2710 Monitoring Visits and Contacts

Revision 24-5; Effective Nov. 1, 2024

Program Standard: The caseworker must monitor the person's situation, the service(s) the person receives, and the adequacy of the service plan per the requirements of the specific service they receive.

Monitoring the service plan includes:

  • ensuring the person is authorized for the correct Community Care Services Eligibility service or program;
  • checking for the appropriate priority level; and
  • ensuring that the authorized hours or units of service meet the person's needs.

2710.1 Monitoring Initiation of Services

Revision 24-3; Effective July 1, 2024

In most situations, the three-day and 30-day initiation of service monitoring visits are not required for Community Care Services Eligibility (CCSE) cases. Phone or face-to-face monitoring visits to ensure service initiation are required for two groups of people:

  • those with priority status, both three-day and 30-day; and
  • those using the Consumer Directed Services (CDS) option for service delivery, for 30-day only.

Review Section 6332.3, Monitoring CDS Service Initiation.

For these two groups, the caseworker 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.

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

  • person's medical condition to ensure their health and safety;
  • dependability of the person's family or friends resource system;
  • impact of environmental circumstances such as 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, caseworkers should verify service initiation by:

  • contacting the person by phone 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 person with notice to contact the caseworker if services are not initiated within a designated time frame.

2710.2 Monitoring Ongoing Services

Revision 24-5; Effective Nov. 1, 2024

The minimum requirements for 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 first 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 make a face-to-face visit within six months of the last monitoring contact date. Example: If the previous monitoring contact was made on March 15, the next contact is due on or before Sept.14.

    Note:  Other possible circumstances 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, 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 more monitoring, or problems may arise that require more contact. Recipients with weak or informal support systems may need to be seen more frequently. Home visits may be necessary 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. Use Form 2068, Application, Redetermination, or Monitoring for Community Care Services, unless there is an indication of abuse, neglect or fraud.

Related Policy

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

2710.3 Service Plan Changes at the Monitoring Contact

Revision 24-5; Effective Nov.1, 2024

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

  • 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 caseworker uses their judgment to determine if the person's long-term improvement is expected to last through the current authorization period or beyond before reducing or terminating services. Review Section 2721.6, Long-term Versus Short-term Changes in the Person's Condition, for more details to make that determination.

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

Caseworker 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 24-5; Effective Nov.1, 2024

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-month and annual. Note: All other contacts must be documented. During each monitoring visit, assess the quality of services and if the services continue to meet the needs of the recipient by determining that:

  • services are delivered per 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. Review 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 per 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?

The recipient or the provider agency may request changes in services.  Document all requests for changes on Form 2067, Case Information, and include the date the request was received. If the recipient requests a change during the monitoring contact, document the request, the request date, 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 24-5; Effective Nov. 1, 2024

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

2711 Monitoring Community Attendant Services People

Revision 24-5; Effective Nov. 1, 2024

People receiving Community Attendant Services (CAS) are eligible for personal attendant services (PAS) under the provisions of Section 1929(b) of the Social Security Act. The act requires the caseworker to monitor the home and community care by visiting each person’s home or community setting where care is being provided at least once every 90 days.

An HHSC caseworker must meet this requirement by conducting a face-to-face visit with the person receiving CAS in the person’s home or community setting where CAS services are being provided. This face-to-face visit must occur at least once every 90 days. The 90-day visit will be for monitoring the person’s satisfaction with services.

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

  • The 90-day monitoring must be completed at least every 90 days with the person or primary caregiver present in the location where services are delivered.
  • All attempts to contact the person must be documented 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 person.
  • If the 90-day monitoring visit becomes delinquent, it must still be completed at the earliest possible opportunity. The caseworker must document all attempts to contact the person and the reason for the delay until the monitoring is completed.
  • In cases where the person 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 person has returned to the home or community setting where services are provided. The caseworker must document the dates and reasons for the person's inaccessibility.

Federal law specifically requires home 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 on March 15, the next monitoring visit must be on or before June 13, the 90th day after March 15. Review Appendix XVIII, Time Calculation.

For CAS cases, HHSC staff 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 caseworker is not required to conduct a 90-day monitor home visit before the SOC date determined by the regional nurse. Once the initial SOC has been determined, HHSC staff 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 caseworkers conduct the annual reassessment simultaneously with the 90-day monitor due before 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. Review Section 7300, Service Authorization System (SAS) Wizards and Use Requirements, and Section 8170, Service Authorization System Help File, for help completing the SASO monitoring visit.

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

2712 Six-Month Monitoring Contacts

Revision 24-5; Effective Nov. 1, 2024

When a six-month monitoring contact is required but a home visit is not, the contact may be completed by phone. If the person does not have a phone or cannot communicate by phone, and a caregiver or relative can tell the caseworker about the person'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 phone with the person, caregiver or responsible relative, a face-to-face visit is required. All attempts to contact the person must be documented.

Before a face-to-face or phone contact is made with someone other than the person, make at least two attempted contacts with the person. Document all attempts to contact the person.

For a priority status person, the six month monitoring contact must be a face-to-face visit within six months of the previous contact. Example: If the previous monitoring contact was made on March 15, the next contact is due on or before Sept. 14.

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

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

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

  • phone contact shows a significant change and the caseworker cannot adequately assess the situation without a home visit Review Section 2721, Functional Changes;
  • contact shows a need to add a service or increase hours Review Section 2663.2, Determining When a Home Visit is Necessary for Other Services; or
  • person shows dissatisfaction with services and the caseworker cannot adequately assess the situation without a home visit.

A face-to-face contact is not required if the person 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 24-5; Effective Nov. 1, 2024

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

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

2721.1 Person's Responsibility to Report Changes

Revision 24-5 Effective Nov. 1, 2024

Discuss with the person the importance of reporting changes. Explain the consequences of failing to do so. If the person 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 person will not:

  • be home when services are scheduled; or
  • need services when scheduled, important for people with priority status receiving personal attendant services.

2721.2 Provider Responsibility to Report Changes

Revision 24-5; Effective Nov. 1, 2024

Attendants report to their supervisors any changes in the person's status or environment that threaten the person's health or safety, or that may affect their service plan. The provider’s supervisor reports these changes to the caseworker. Examples of these changes include hospitalizations, episodes of illness, changes in functional abilities, bruises, mental instability that endangers the person 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 person to Adult Protective Services.

If a provider fails to report changes that affect a person's service plan, the problem must be discussed with the 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 24-5; Effective Nov. 1, 2024

The caseworker will use their judgment to decide if they have enough information to respond to the reported change without visiting the person. If in doubt, a home visit should be made. Consider the following when making that determination:

  • Is the caseworker already very familiar with the person'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 person now needs and what the person is saying they need?

Make a home visit and complete a functional reassessment if the person needs or requests a new service, and their 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 person:

  • requests a reduction or termination;
  • gains a resource resulting in fewer 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 24-5; Effective Nov. 1, 2024

Program Standard: The caseworker must revise the service plan within 14 calendar days of learning that the person's status or condition changed, or must document why no changes to the service plan are needed. If the caseworker becomes aware of the need for a service plan change because of conducting an annual reassessment, the change must be completed as part of that reassessment.

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

  • Form 2060, Needs Assessment Questionnaire and Task/Hour Guide;
  • personal assistance services tasks;
  • priority level; and
  • number of hours or units of service the person is authorized to receive per week.

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

Revision 24-5; Effective Nov. 1, 2024

The caseworker uses their judgment to determine if the change in the person'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 person is experiencing temporary improvement in functional condition.

If it is determined the person's condition has temporarily improved because the person is performing tasks previously done by the attendant, the person 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 person agrees to the reduction. In this situation, the caseworker would not update the Service Authorization System Online (SASO) record or send Form 2065-A, Notification of Community Care Services, to the person for a reduction of hours.

If a change in the person's condition impedes their functional ability to perform activities of daily living, it may be necessary to add additional hours or tasks to the service plan. Caseworker 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 enough to meet the person's needs.

2721.6 Authorizing and Documenting Changes

Revision 24-5; Effective Nov. 1, 2024

Document all requests for changes in services, including the date of the request, whether received from the person or the provider.

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 or hours, update and submit Form 2101, Authorization for Community Care Services. Send Form 2065-A, Notification of Community Care Services, to the person if the:

  • Primary Home Care, Community Attendant Services, or Family Care hours increase or decrease;
  • person 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 change request. If it is determined that no revision is needed in the service plan, document the decision and the reason. Use Form 2067, if the provider or regional nurse requested the change.

2722 Person Moves and Case Transfers

Revision 24-5; Effective Nov. 1, 2024

At times, a person's move requires transferring the person's case to a new caseworker within the same region or a different region.

When a person moves to an area served by a different caseworker 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. Make every effort to minimize gaps in coverage for the person. Although the old plan remains in effect until amended, actual services may have to be temporarily suspended. Example: The new area or region does not have space in a Residential Care (RC) or Day Activity and Health Services (DAHS) facility. The caseworker who is notified of the move should initiate the action for the transfer.

2722.1 Procedures If the Losing Caseworker Initiates Action

Revision 24-5; Effective Nov. 1, 2024

If the current, losing, caseworker is contacted by the person or the person’s representatives, and the person has not already moved, that caseworker must:

  • contact the office in the new location and get the name, address, and phone number of the gaining caseworker to give to the person;
  • contact the gaining caseworker by phone and discuss the case;
  • provide the gaining caseworker with the individual number so the caseworker can access the Service Authorization System Services (SASO) for current  information;
  • have the gaining caseworker 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 person in the new location, the losing caseworker keeps Form 2101, Authorization for Community Care Services, open and the gaining caseworker makes any needed changes.
    • if moving to another region, the provider number may be different even if the person is staying with the same agency;
  • provide the person with the caseworker and provider information and if the person has selected a new provider, relay that information to the gaining caseworker with a projected date of transfer;
  • forward the case record to the gaining caseworker within three business days of confirming the move;
  • send Form H1746-A, MEPD Referral Cover Sheet, if applicable, advising of the new address so that the MEPD case can also be updated; and
  • advise staff for any other services the person is receiving that the person has moved. 

2722.2 Procedures If the Gaining Caseworker Initiates Action

Revision 24-5; Effective Nov. 1, 2024

It is the gaining caseworker's responsibility to:

  • update Form 2101, Authorization for Community Care Services, by entering in the comments section that this is a transfer case and including 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 caseworker that Form 2101 has been updated when then must print a copy of Form 2101 and send it to the losing provider;
  • update any current Community Care Interest List entries for the person for the new area;
  • send Form H1746-A, MEPD Referral Cover Sheet, for all Community Attendant Services (CAS) people to Medicaid for the Elderly and People with Disabilities (MEPD);
    • advise that the person has moved to the service area and has a continued need for service;
    • provide the old and new addresses;
  • contact the person within 14 calendar days to assess the person's new living arrangements and need for service plan changes;
  • schedule a home visit If needed; and
  • review 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 24-5; Effective Nov. 1, 2024

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

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

  1. Ask the person or their representative to select a new provider and document the choice.
  2. Coordinate with both providers the date the current provider will stop providing services and the date the new provider will begin services.
  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 documenting the coordination with both 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 caseworker will send the current, losing provider a copy of the updated form that reflects the effective date of the transfer.

In situations that the person has been suspended due to health and safety reasons and services will continue with a new provider, the HHSC caseworker must determine how much information to share with the new provider about the previous actions. Review Section 2840.1, Sharing Information with New Providers Regarding Health and Safety Issues.

2724 Medicaid Coverage for People Denied SSI

Revision 24-5; Effective Nov.1, 2024

In most instances:

  • receipt of Supplemental Security Income (SSI) entitles a person to Medicaid; and
  • loss of SSI eligibility also means loss of Medicaid benefits.

However, there are several exceptions to this, particularly when someone loses SSI eligibility because of income from Social Security benefits. If a CCSE person receives both SSI and Social Security benefits and the SSI is denied because of income associated with Social Security, encourage the person to apply to Medicaid for the Elderly and People with Disabilities (MEPD)  for an eligibility determination. Send a H1746-A, MEPD Referral Cover Sheet to MEPD if the person is interested.

2725 Certificates of Insurance Coverage

Revision 24-5; Effective Nov. 1, 2024

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 a person ceases coverage under a plan or policy. The certificate provides evidence that the person had prior creditable health insurance coverage that counts toward reducing or eliminating pre-existing condition exclusions under any subsequent health insurance coverage the person may get.

This legislation will affect people who are Medicaid recipients. Information about certificates of coverage is provided to CCSE applicants and people 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 people. If a person has questions about the certificate or needs a replacement certificate, they 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 People Entering a Nursing Facility

Revision 24-5; Effective Nov. 1, 2024

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

If a person wants to enter a nursing facility, help them make their plans. If the person is not a Medicaid recipient, refer them to Medicaid for the Elderly and People with Disabilities (MEPD) staff to start the financial application process as soon as possible.

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

Nursing Facility Care for People Under 22

State Law Chapter 242, Health and Safety Code requires that the Community Resource Coordination Group (CRCG) be notified by the third day after the date a Community Care Services Eligibility child under 22 with a developmental disability is initially placed in an institution.

Call the CRCG State Office at 512-206-4564 to get the name and phone number of the CRCG contact person. A CRCG list is also available online (PDF).

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 an 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 People Entering a Nursing Facility

Revision 24-5; Effective Nov. 1, 2024

A batch process closes the service authorization records for Community Care people 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 the above transaction, on Form 3618 as the end date of the service authorization.

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

2732.2 People Leaving a Nursing Facility

Revision 24-5; Effective Nov. 1, 2024

For people being discharged from a nursing facility who are beginning to receive 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 caseworker 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 caseworker must confirm the person 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 caseworker must identify themself as a Texas Health and Human Services Commission (HHSC) employee and report that the person 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 caseworker documents the contact. 

2732.3 People Denied a Determination of Medical Necessity

Revision 24-5; Effective Nov. 1, 2024

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

If the person requests CCSE services, respond to this request by following the usual intake procedures, including interviewing, and assessing their needs. If the person 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 caseworker 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 24-5; Effective Nov. 1, 2024

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

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

MFP does not apply to Community Care Services Eligibility programs.

Review the appropriate program handbook for the desired waiver program for more information.

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 Texas Department of Corrections (TDC) People Leaving TDC

Revision 24-5; Effective Nov. 1, 2024

Texas Department of Corrections (TDC) staff are responsible for discharge planning for people who are older or people with disabilities being released from TDC. TDC tries to make a referral at least 30 calendar days before the inmate will be released from prison. TDC is represented in the community by the Board of Pardons and Parole (BPP). BPP supervises the person in the community and provides or arranges for other services they may need. Follow the usual case management procedures to certify the person eligible for services, to refer their case for service, and to monitor or evaluate any services authorized.

2735 People Who Need Hospice Services

Revision 24-5; Effective Nov. 1, 2024

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

Hospice staff contact the caseworker by phone about the start and cancellation dates for hospice care. Hospice staff no longer send a copy of Form 3071, Individual Election/Cancellation/Update, to HHSC staff. People may elect or cancel hospice care at any time.

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

HHSC caseworkers must follow up with the person receiving services to determine what hospice will provide and adjust the person’s service plan to ensure no duplication of services. Caseworkers must respond to a notification of hospice election within the time frame of a change request.

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

If the hospice provider does not meet the need for help, or if the need is only partly met, authorize services on the same basis as those used for any other person.

Caseworkers may receive a request to initiate a CCSE service for a person already receiving that service from a hospice. In this case, it must be determined if the hospice will continue to provide the needed care. Authorize the CCSE service if the hospice service ends on a certain 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 to prevent a break in services. When a CCSE person enters a nursing home under hospice, terminate CCSE services effective the date the person entered the facility. If the person receives hospice care at home, making reduction or termination of CCSE services necessary, give the person the usual 12-day advance notice before the effective date of the reduction or termination.

If a person 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 caseworker notifies the MEPD of the Hospice nursing facility entry and closure of the HHSC case by sending Form H1746-A, MEPD Referral Cover Sheet.

In related situations, hospice services should be considered as a resource available to CCSE applicants and recipients. Monitor CCSE people on an ongoing basis to determine if they need or are receiving hospice services.

Note: Refer to Section 1140, Disclosure of Information, about 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 24-5; Effective Nov. 1, 2024

The applicant or person 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 calendar days of the date the Texas Health and Human Services Commission (HHSC) receives it; and
  • resolve it within 60 calendar days of that date.

2736.1 Reporting Service Delivery Issues

Revision 24-5; Effective Nov. 1, 2024

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

  • the person or person's representative;
  • Texas Health and Human Services Commission (HHSC) staff, including issues discovered by the caseworker or reports received during monitoring contacts; and
  • other people, including the person's family and friends.

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

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

This list is not all-inclusive.

Report 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 to Consumer Rights and Services at 800-458-9858 or ciicomplaints@hhs.texas.gov to generate an investigation by HHSC Regulatory Services.

Within five business days of receiving a report or becoming aware of service delivery issues, the caseworker:

  • must respond to the person and the provider either by phone or face-to-face contact to discuss the issues;
  • must inform the provider of the service delivery issues and discuss resolutions;
  • convenes an interdisciplinary team (IDT) meeting if appropriate;
  • coordinates with the person and provider to implement actions required to resolve the issues;
  • must document the receipt of the report and contacts with the person and the provider in the case record;
  • must document any barriers or hindrances by either party that interfere with the resolution of the issues; or
  • attempts to resolve the issue must be documented.

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

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

The caseworker must make the report to the HHS Office of the Ombudsman within three business days after the 10 business day resolution period ends.

In situations where service delivery issues may compromise the person's health and safety, the caseworker must report within 24 hours of receiving the report or becoming aware of service delivery issues. The caseworker 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 person; and
  • continue to work with the person and provider to resolve the issues within the 10 business day time frame.

The caseworker must identify the specific service the provider is delivering when calling to report a complaint.  Example: the caseworker identifies the provider as a Primary Home Care (PHC) provider when making a referral that involves PHC service delivery issues. The caseworker must provide specific information related to the service delivery issues, including actions taken to resolve the issues and why the actions did not resolve them.

2740 Fraud Detection and Documentation

Revision 17-1; Effective March 15, 2017

 

2741 Provider Fraud

Revision 24-5; Effective Nov. 1, 2024

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 people. However, when there is an indication of potential fraud, the allegations must be investigated, and the following must be established:

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

Examples of provider fraud include:

  • 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.

Note:  This list is not all-inclusive.

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 24-5; Effective Nov. 1, 2024

People receiving HHSC services are perceived as honest and entitled to the same protection under the law as all other people. However, when there is an indication of potential fraud, the allegations must be investigated, and the following must be established:

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

Examples of individual fraud include:

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

Note:  This list is not all-inclusive.

2744 Responding to Allegations of Individual Fraud

Revision 24-5; Effective Nov. 1, 2024

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 and where the conduct occurred;
    • how the fraudulent action was performed; and
    • the names of people who are knowledgeable about the situation and how they can be contacted.
  2. If a third party alleges fraud, staff should try to get the complainant's name, address, and phone number so 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 about the investigation or any possible adverse action.

Restitution must not be requested in cases where fraud is being pursued. Restitution is securing payment from a person 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 24-5; Effective Nov. 1, 2024

The following are established procedures for reporting suspected fraud in the Consumer Directed Services (CDS) option to the Office of Inspector General (OIG). These apply when there is suspected fraud committed by the person receiving services, the CDS employer or the CDS employee. They do not apply to provider fraud.

When the HHSC caseworker suspects fraud was committed by the person 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 caseworker must report the suspected fraud to the OIG. The caseworker can submit the referral using the OIG website, or by calling 800-436-6184. The caseworker must inform the OIG the person is using the CDS option.

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

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

  • name of the FMSA;
  • name of the person(s) suspected of committing fraud;
  • 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 because 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 caseworker who submitted the referral and the HHSC office where the caseworker is located.

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

The FMSA also informs the HHSC caseworker that a fraud referral was submitted to the OIG using Form 2067. The caseworker must file Form 2067 received from the FMSA in the person’s case file. No further action is needed by the caseworker about the fraud referral once the FMSA notifies HHSC the referral was made to the OIG.

2750 Fraud Referral

Revision 24-5; Effective Nov. 1, 2024

 

2751 Development of the Fraud Referral Packet

Revision 24-5; Effective Nov. 1, 2024

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 will be submitted, complete the online reporting document, Form H4834, Individual or Recipient Provider Fraud Referral/Status Report, available at the Inspector General webpage. The online reporting system prompts 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 including the name, provider type and specialty, business address, residence address and provider numbers;
    • identification of the alleged illegal act including specific data about potential witnesses, addresses, work and home phone numbers;
    • names, mail codes and phone numbers of all staff who can provide information;
    • identification of policy, regulation or procedural violations;
    • citing the appropriate numerical reference and manual title, the department rule or policy clearance letter;
    • include in the reference the specific chapter, subchapter, page number and effective date of the manual or publication source;
    • show who or what initiated the allegation; and
    • other pertinent documentation about the case.

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

2752 Expedited Referrals

Revision 24-5; Effective Nov. 1, 2024

If staff have reason to believe that the conduct of the suspected provider, person 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 a person;
  • 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 800-436-6184 or ReportTexasFraud.com before the referral packet is produced. The HHSC representative instructs staff as to what portions of the required information should be completed and sent.

2753 Referral of Potential Fraud

Revision 24-3; Effective Nov. 1. 2024

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 request more information later. 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, person 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.

2800, Notifications, Suspensions, Denials and Terminations

2810 Individual Notification Procedures

Revision 24-5; Effective Nov. 1, 2024

Program Standard – Within two business days after the decision, notify the person in writing. Use the SASO generated Form 2065-A, Notification of Community Care Services, of all eligibility and ineligibility decisions or any changes in the person’s service plan. Review Form 2065-A, Instructions.  

When notifying the applicant of eligibility, specify on Form 2065-A:

  • the Community Care Services Eligibility (CCSE) services that the applicant is eligible or ineligible for; and
  • if determined eligible:
    • the number of hours of services the applicant is authorized to receive or the number of days or half days the applicant is authorized to attend a Day Activity and Health Services (DAHS) facility;
    • if applicable, that the Family Care, Primary Home Care or Community Attendant Services applicant is eligible for priority status;
    • the initial and ongoing room and board payments for Residential Care and Adult Foster Care; and
    • the initial and ongoing copayments the Residential Care the person will pay to the facility.

An applicant or person certified for one CCSE service but determined ineligible for another must be notified in writing of both decisions. An applicant or person certified for personal attendant services or home-delivered meals must also be notified in writing of the hours per week or meals per week they are eligible to receive. If certified for DAHS, the applicant or person must be notified in writing of the number of days per week the DAHS authorization covers. The written notice for all services must contain the caseworker's name, phone number and appeal procedures.

For ongoing people, on Form 2065-A, record the:

  • action taken and the effective date; and
  • name of the CCSE service(s) that the action is based.

If the notification is an adverse action, the notice must also state the:

  • reason for the adverse action; and
  • CCSE Handbook reference that the adverse action is based on.

Review the Form 2065-A Attachment for handbook and rule references.

CCSE staff may notify a person verbally of continued eligibility if the person continues to qualify for the same service(s) and the number of hours or units of service remains the same. 
 

2811 Effective Dates

Revision 24-5; Effective Nov. 1, 2024

The Texas Health and Human Services Commission (HHSC) caseworker notifies the applicant or recipient using Form 2065-A, Notification of Community Care Services of any action that denies, suspends, reduces, or terminates services. In general the HHSC caseworker sends the notice of adverse action to the person 12 calendar days before the effective date of the action. In situations that services were suspended due to threats to health and safety, the HHSC case worker sends the written notice of adverse action without advance notice if the crisis cannot be resolved.

An applicant or recipient has the right to appeal any decision that denies, reduces, or terminates their services and request a fair hearing per Title I, Texas Administrative Code (TAC) Section 357.

For an adverse action, if the day after the effective date is a Saturday, Sunday or legal holiday, the adverse action period is extended to include the next day that is not a Saturday, Sunday or legal holiday. Skeleton crew days are not legal holidays. Legal holidays are days when the agency is closed. Review Appendix IX, Notification Effective Date of Decision, Appendix XVIII, Time Calculation and Section 2652, Changing the Service Schedule Between Reassessments for information about calculating effective dates of reduction or termination of services.

The date at the top of Form 2065-A is the date the HHSC caseworker completes the form. Since offices have different mail pickup times, staff are not required to consider the mail date when completing the form. Staff must ensure applicants and recipients are notified within the required time frames.

Services are reduced or terminated at annual reassessment or any other time the caseworker becomes aware before the annual review when the person:

  • 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 resulting in the need to reduce or terminate services.

People may request an appeal of any decision that denies, reduces, or terminates their benefits. The effective date of the action depends on the situation, as shown in the following table:

If Then 

Termination or reduction is because the person:

  • lost their eligibility as an income-eligible;
  • failed to qualify as an income-eligible after a verbal referral,
  • failed to meet the client needs assessment score or medical criteria for the service;
  • more than three times directly or knowingly and passively condoned the behavior of someone in their home and, therefore, refused to follow the service delivery provision;
  •  experienced a change in their need for the specific service; or
  • failed to pay Residential Care Copays.
The action is effective 12 calendar days from the date of the notice unless the action is appealed. In the event of an appeal, services continue until the hearings officer gives a decision. The cost of providing services during this period is subject to recovery by the department from the person. Services to people in Residential Care facilities are terminated five days after the hearings officer gives their decision.
Termination is because the person loses Medicaid or categorical eligibility.Services continue only to the end of the month that the person is determined ineligible, even if the action is appealed.
Termination is because the person lacks practitioner’s orders for the service.Services continue only through the date the previous orders end, even if the action is appealed.
Termination or reduction is because of budgetary constraints or changes in federal law or state regulations, and services are reduced or terminated for an entire categorical group of people.Services continue only through the date of termination of a categorical group of people, even if appealed.
Termination is because the person or someone in their home threatens the health or safety of others, or because the person threatens their own health or safety.

Services may be terminated immediately under the following conditions:

  • a person receiving Residential Care (RC), Adult Foster Care (AFC), Day Activity Health Services (DAHS), or Special Services to Persons with Disabilities (SSPD) threatens their own health or safety or that of others; or 
  • someone in the person's home or a person receiving Emergency Response Services (ERS), Home-Delivered Meals (HDM), Family Care (FC), Primary Home Care (PHC), Community Attendant Services (CAS) or SSPD threatens the Texas Health and Human Services Commission (HHSC) staff or provider's health or safety.
Termination or reduction is because of budgetary constraints or changes in federal law or state regulations, and services are reduced or terminated for an entire categorical client group,Services continue only through the date of termination of a categorical client group, even if appealed.

2812 Changes in the Person's Need for Services

Revision 24-5 Effective Nov. 1, 2024

Before reducing or terminating services caseworkers determine if the person's long-term improvement is expected to last through the current authorization period or beyond.

If it is determined that the person's condition has temporarily improved because the person is performing tasks previously done by the attendant, the person and provider may agree to fewer hours per week.

Do not reduce or terminate services if it is determined the person is experiencing temporary improvement in their functional condition. If the person feels they temporarily need fewer hours, send the provider Form 2067, Case Information, informing the provider that fewer service hours may be provided if the person agrees to the reduction. If the person is experiencing temporary functional improvement, the caseworker would not change the task and hour guide or authorization or send Form 2065-A, Notification of Community Care Services, to the person for reduction of hours.

The person and provider may agree to change the delivery schedule for personal attendant services (PAS) hours based on the person's needs without prior approval from the caseworker.

Caseworker approval or denial is required for all requests to increase PAS hours previously authorized or to add or delete priority status. In these situations, terminate or reduce services 12 calendar days after the Form 2065-A completion date. Review Section 2652, Changing the Service Schedule Between Reassessments, Section 2811, Effective Dates and Appendix XVIII, Time Calculation.

2813 Situations in Which the 12-Day Adverse Action Period May Be Reduced

Revision 24-5; Effective Nov. 1, 2024

There may be situations when a person wants to waive or shorten the 12- calendar day notice period before services are reduced or terminated. Some examples of these situations include:

  • A Family Care person is being removed from an interest list for Title XX Day Activity and Health Services (DAHS) and wants to withdraw or have services reduced in less than 12 calendar days to attend DAHS immediately; or
  • Community Care Services Eligibility People who prefer to receive 1915(c) waiver services may also wish to have the change take place in less than 12 calendar days.

If the person indicates a desire to waive or reduce the 12 calendar day advance notice, be very cautious and remember that a person may change their mind. In most instances, the provider can be verbally notified to stop service and still maintain the formal effective date of 12 calendar days in the future.

If the person still wants to waive or shorten the 12 calendar day advance notice, complete Form 2065-A, Notification of Community Care Services, with the effective date being the date the person wants services to end or be reduced. Explain in the comments section that the person is voluntarily waiving or reducing their right to the 12-calendar day advance notice. The person must:

  • sign this statement; and
  • be given the original and one copy of the notice.

2814 Transfers Between Primary Home Care, Community Attendant Services and Family Care

Revision 24-5; Effective Nov. 1, 2024

Send Form 2065-A, Notification of Community Care Services, when a person is transferred from any of the three programs listed to any of these programs:

  • Primary Home Care (PHC);
  • Community Attendant Services (CAS); or
  • Family Care (FC).

Do not send another form to terminate the previous service. Specify on the form:

  • name and amount of the previous service;
  • name and amount of the new service;
  • the effective date of the transfer; and
  • reason for the transfer.

Show in the comments section that the person should not notice any difference in the amount or type of services received because of this transfer.

Example: The service you were receiving, Primary Home Care, 16 hours a week, will change to Family Care, 16 hours a week, effective June 1, 2024.

Comments: Primary Home Care will terminate because you lost financial eligibility for that program. You should not notice any difference in the amount or type of services you will receive because of this transfer.

Although Form 2065-A must be sent when a person transfers between PHC, CAS, and FC, the effective date is either the negotiated date or the date following the Medicaid end date.

Review Section 4600, Primary Home Care and Community Attendant Services, for more transfer procedures.

Refer to Appendix IX, Notification/Effective Date of Decision, and Appendix XVIII, Time Calculation, for other exceptions to the 12 calendar day notice requirement. The effective date of the transfer does have to be at least 12 calendar days following the date of notification if the number of hours is decreased.

2820 Service Suspensions

Revision 24-5; Effective Nov. 1, 2024

Services may be suspended by the provider or by the caseworker.

2821 Service Suspension by Providers

Revision 24-5; Effective Nov. 1, 2024

Providers may suspend services to people. Review Section 4000, Specific CCSE Services for information about suspensions of each specific service.

On the day of suspension or by the first HHSC business day following suspension, the provider must contact the caseworker to explain the reason for suspending services.

If a person meets the criteria for Adult Protective Services (APS), refer them. Refer other people to other appropriate service resources as needed.

The caseworker documents the incident that caused the suspension and the date of the incident. The results of any related interdisciplinary team (IDT) meetings must be included in the documentation. After evaluating suspensions to determine if services should be terminated and the case closed, the caseworker takes the appropriate action. In some situations, the problems that caused the suspension can be resolved. If they are resolved:

  • send Form 2067, Case Information, to the provider documenting the problem resolution; and
  • reach an agreement with the provider about the date on which services will be reinstated.

2822 Service Suspension by Caseworkers

Revision 24-5; Effective Nov. 1, 2024

A person is not eligible for CCSE services when:

  1. they die;
  2. they are admitted to an institution;
  3. for Medicaid services only, their physician requests service termination;
  4. they request service termination or repeatedly refuse to accept help, except in an involuntary protective services case; or
  5. they refuse to comply with their service plan.

Related Policy

26 Texas Administrative Code Section 271.155(c)

2822.1 Hospital and Nursing Facility Stays

Revision 24-5; Effective Nov. 1, 2024

Suspend services when available information confirms that a nursing home or hospital stay will be longer than 30 calendar days. Use Form 2067, Case Information, to notify the provider to suspend services effective the date of nursing home or hospital entry. Sending updates to the provider is optional.

Continue to monitor the situation. If the person has not returned home by the 30th calendar day, contact the person or authorized representative (AR) to see if a discharge date is planned. If the person has a planned discharge date within the next 30 calendar days, leave the case open and monitor on the planned discharge date.

Terminate services, using the date of admission as the effective date of termination, if information shows that the nursing facility or hospital stay will be more than 30 calendar days.  Exception: The effective date of termination for Residential Care should be the 30th day after admission to the nursing facility or 60 days after admission to a hospital.

Consult with the person, family, and others associated with the person to determine the length of stay. Be cautious about terminating Title XX services, especially if the region has an interest list for those services.

Emergency Response Services (ERS) may remain open until the decision is made to terminate all services because the nursing facility stay has become permanent. Review Section 4300, Emergency Response Services, for suspension of ERS by the ERS provider.

The following situations should always be considered short-term, and services should be suspended for up to 30 calendar days rather than terminated:

  • admission to a swing bed facility; and
  • admission to a hospital for mental illness treatment.

Services may be suspended indefinitely if the person is admitted to a rehabilitation hospital or to a rehabilitation floor or wing of a medical hospital.

2830 Refusal to Comply with Service Delivery Provisions

Revision 24-5; Effective Nov. 1, 2024

Examples of refusal to comply with the service delivery provisions include, but are not limited to:

  • The person is often away from their residence when a service is scheduled. They repeatedly fail to notify the provider that they will be gone, even though they have been counseled about this problem and its implications.
  • The person or someone in the person’s home will not permit the provider to perform one or more of the tasks in the service plan regularly. The person receives personal attendant services and refuses to allow the provider to perform the authorized tasks.
  • Despite several provider efforts to find and place an acceptable attendant in the home, the person refuses to accept services because of dissatisfaction with a particular attendant.
  • The person or someone in the person’s home regularly behaves in such an offensive way to staff that staff refuses to serve them. The person knowingly and passively condones the abusive behavior, and the staff cannot provide services. Examples include sexual harassment, sexual misconduct and racial discrimination.

If the provider notifies the Texas Health and Human Services Commission about a service delivery compliance problem, contact the person or the responsible party. Attempt to resolve the issue in a way that is satisfactory to the person and the parties involved. An interdisciplinary team (IDT) meeting may be conducted at the person’s home to try to resolve the situation.

Related Policy

26 Texas Administrative Code Section 271.155 
 

2830.1 People Who Refuse to Comply with Electronic Visit Verification Requirements

Revision 24-5; Effective Nov. 1, 2024

People requesting or receiving personal attendant services are required to participate in Electronic Visit Verification (EVV) by allowing the attendant to use their home landline to report the start and the end of work. If a person does not have a home landline, or will not allow the attendant to use the home landline, the person must agree to an alternate device installation in the home. Failure to cooperate with EVV requirements can result in suspension or termination of services.

It is the caseworker’s responsibility to review the information on the rights and responsibilities form and adequately explain the EVV requirements to the applicant or person receiving services. It is important to communicate that a person’s failure to cooperate with EVV requirements can result in the suspension or termination of services. The caseworker must explain the following points:

  • EVV is a phone and computer-based system that electronically verifies service visits occur and documents the precise time service provisions begin and end. The purpose of EVV is to verify that people are receiving the services authorized for their support and for which the state is being billed.
  • EVV will not change the services the person receives.
  • EVV is mandatory for all provider agencies and people receiving services from an attendant unless the person receives services through the CDS option.
  • The attendant needs the person’s permission to use the home landline to call the toll-free number at the start and at the end of work. Under no circumstances should the person call the toll-free number on behalf of the attendant. If the person is asked to do this, they should report it to the provider agency.
  • If the person does not have a home landline or does not want the attendant to use their phone, an alternative device can be placed in the home, which is used only to verify the attendant’s start and end of work. This device must always remain in the home. If the person notices the removal of the device, they should report it to the provider agency.
  • If the person notices any other possible EVV violation such as an instance where the attendant leaves the home without providing services after calling the toll-free number upon arrival, they should report it to the provider agency.
  • If the person has more questions, the caseworker refers them to the selected provider agency or Financial Management Services Agency (FMSA) for additional information on how EVV works.

For people using the CDS option, the caseworker must explain that the person receiving services, or a designated representative (DR), is the employer of record and can choose to use the EVV system or use paper time sheets. The three choices are:

  • Full Participation-Phone and Computer: The CDS employee(s) use the phone portion of EVV, and the employer of record uses the computer portion of the system to perform visit maintenance.
  • Partial Participation-Phone Only: This option allows the employer of record to participate in EVV but provides some help from the FMSA with visit maintenance. The CDS employee calls in when they start work and calls out when they end work. The employer uses a paper time sheet to document service delivery. The FMSA performs visit maintenance to make sure the EVV system matches the paper time sheets approved by the CDS employer.
  • No EVV Participation: If the employer of record does not have access to a computer, assistive devices, or other supports, or feels they cannot fully participate in EVV, they may choose to use a paper time sheet to document service delivery.

The FMSA will require the employer of record to complete Form 1722, Employer’s Selection for Electronic Visit Verification (EVV), to indicate their choice.

If a person is refusing to cooperate with EVV requirements, it is considered a refusal to comply with service delivery provisions and policies in Section 2831, Suspensions Due to Refusal to Comply with Service Delivery Provisions. Some people whose provider is required to participate in EVV are not allowing the attendant to use their home phone and are also refusing to allow a Fixed Visit Verification (FVV) device to be placed in their home.

Providers are required to participate in EVV for services delivered by an attendant. People who refuse to allow the attendant to record hours worked through EVV, either through using their home phone or a FVV device, are non-compliant with their service delivery plan. These people are essentially not allowing the provider to carry out services per provider requirements.

2831 Suspensions Due to Refusal to Comply with Service Delivery Provisions

Revision 24-5; Effective Nov. 1, 2024

The provider or caseworker may suspend services until an interdisciplinary team (IDT) meeting is scheduled and the situation is discussed. After the IDT meeting, the caseworker must send the person a letter within five working days stating services can be terminated if they do not comply with service delivery provisions and stating specifically what the person must do to continue services.

If the situation is not resolved and the person continues to refuse to comply, the caseworker convenes a second IDT and sends the person a second letter stating that continued refusal to comply with service delivery provisions will result in the termination of services.

If the situation continues be unresolved and a third situation arises, the caseworker convenes a third IDT. They must send a third and final letter to the person stating that continued refusal to comply with service delivery provisions will result in the termination of services.

If the situation continues, the caseworker may terminate services by sending Form 2065-A, Notification of Community Care Services. Review Section 2810, Individual Notification Procedures. A CCSE supervisor must approve denials based on a refusal to comply with service delivery.  Document the conference and supervisory approval.

There is no period where instances of refusal to comply must occur.

2832 Documentation of Compliance Issues

Revision 24-5; Effective Nov. 1, 2024

Documentation is required in all situations involving the person's refusal to comply with service delivery provisions. Opinions or evaluative conclusions are not appropriate documentation to substantiate a denial of services. Documentation should stress a factual statement of actions constituting noncompliance.

Determine and document if the person is aware of and able to understand the consequences of their or other's actions. If the person is not aware of their behavior or the behavior of someone in their home, discuss the issues with them.

Determine if someone seems to be abusing, neglecting or exploiting the person, and, if necessary, refer them to Adult Protective Services (APS). Continue services pending the APS investigation. APS may take appropriate action, such as obtaining a guardian to resolve the problem if the person is abused, neglected or exploited.

Document the date and content of each discussion with the following:

  • person;
  • interested family member;
  • provider; and
  • unit supervisor.

2833 Reauthorization of Services After Termination for Refusal to Comply

Revision 24-5; Effective Nov. 1, 2024

If a person's services were terminated because of refusal to comply with service delivery provisions that involve a provider, talk with the unit supervisor before sending a referral to another provider. You must discuss the person's particular compliance issues with a CCSE supervisor before reauthorizing services, and the unit supervisor must approve the referral.  Document the approval in the comments section of Form 2101, Authorization for Community Care Services.

Follow these steps when an applicant who was authorized services in the past had services terminated due to their failure to comply with service delivery provisions reapplies:

  1. Before contacting the applicant, review the applicant’s circumstances of the previous denial and the steps to be taken for them with the supervisor. Document the review.
  2. Review with the person or responsible party:
    • the reason for the previous termination;
    • the responsibility of the person or responsible representative to notify the provider and Texas Health and Human Services Commission (HHSC) about problems related to the service delivery provisions and the importance of good communication; and
    • that each task must be authorized, emphasizing that the only tasks the attendant is to perform are those authorized by HHSC.
  3. Authorize services if the person agrees to follow the service delivery provisions.
  4. Document the conversation with the person.
  5. Contact the person or provider weekly for one calendar month to assess the person's compliance with service delivery provisions. If the person continues to have problems complying with service delivery provisions, contact the person and emphasize the need for them to comply.
  6. If the provider complains about the person refusing to follow their service delivery provisions, contact the person monthly after the first month of service. Discontinue monthly contacts when complaints cease.
  7. Terminate services if the person refuses more than three times to comply with service delivery provisions.

Review Section 2831, Suspensions Due to Refusal to Comply with Service Delivery Provisions.

2840 Threats to Health or Safety

Revision 24-5; Effective Nov. 1, 2024

Occasionally, a person  or someone in their home might exhibit behavior that constitutes a threat to the health or safety of another person. Examples include, but are not limited to:

  • exhibiting weapons;
  • making direct spoken threats of physical harm, force or death;
  • physically attacking a person with or without a weapon;
  • threatening use of force by self or someone else;
  • using or selling illegal drugs; and
  • displaying dirty needles or the smell of toxic fumes from the manufacture or sale of illegal drugs in the person's home environment.

The caseworker must immediately notify management if, during the first or any other contact by the caseworker or provider staff, a person or someone in their home exhibits threatening behavior or makes comments that are threatening, hostile or of a nature that would cause concern for the person, provider or Texas Health and Human Services Commission (HHSC) employee. Regional management must review these situations on a case-by-case basis and determine the most appropriate action to be taken. If the applicant's safety may be at risk, the caseworker must follow current policy about notification to the Department of Family and Protective Services Adult Protective Services (APS). If the caseworker believes there is a potential threat to others, regional management should determine the best method for notifying the provider and addressing the person's needs without placing staff members at risk.

If a person threatens their own health or safety by threatening or attempting suicide or self-injury and is at immediate risk, place a 911 call to report the emergency. A referral to APS must also be made. If the applicant or person seems to be abused, neglected, or exploited by the person who threatens the health or safety of others, refer the person to APS.

In most cases where there is a potential for danger, services should be suspended immediately.

The caseworker must send Form 2065-A, Notification of Community Care Services, by the next business day after receiving notice from the provider that services have been suspended for failure to comply or threats to health and safety. The notice must reference 26 Texas Administrative Code Section 271.155 state the last day services are delivered, and include a clear statement in the comments explaining why services were suspended.

Within three business days after the caseworker becomes aware of the suspension, the caseworker must arrange an interdisciplinary team (IDT) meeting to try to resolve the issue with the provider and the person. Depending on the severity of the reason for the suspension, some IDT meetings may be conducted by phone or some may require a face-to-face contact.

The caseworker may conduct the IDT meeting by phone or a face-to-face contact for all suspension reasons listed in this section. Caseworkers are required to discuss the specific case with their supervisors to determine the best approach for conducting the IDT. Caseworkers must document the rationale for conducting the IDT by phone.

During the IDT meeting, the caseworker, provider staff, the person and the person’s representative, if any, must evaluate the issue and discuss the program requirements for continued services. The IDT should identify any solutions to resolve the issue, including the person’s understanding of the issue and what must be done to resolve the issue. The caseworker must document the requirements for continued services. Review Section 2831, Suspensions Due to Refusal to Comply with Service Delivery Provisions, and Section 2832, Documentation of Compliance Issues, for more guidelines.

If the issue leading to suspension is resolved during the IDT, the provider must, within two business days after the IDT meeting, either implement the recommendations of the IDT or discharge the person and refer the person to the caseworker for referral to another provider. The caseworker must notify the person verbally or in writing of the reinstatement of services. If services continue, assess if the person meets the guidelines for a person at risk and if so, follow procedures outlined in Section 2550, Identifying People at Risk. If the issue is not resolved and services cannot be continued, the caseworker begins the termination process.

2840.1 Monitoring or Annual Home Visit Delay Due to Unsafe Environmental Circumstances

Revision 24-5; Effective Nov. 1, 2024

The Texas Health and Human Services Commission (HHSC) caseworker is required to make every reasonable attempt to complete the Community Attendant Services (CAS), Primary Home Care (PHC), and Family Care (FC) service monitoring or annual reassessment visit. All attempts to contact the person must be documented to support the efforts to meet the requirements. In some situations, the caseworker cannot make the face-to-face home visit due to a dangerous environmental situation beyond the caseworker or person’s control. These situations may include but are not limited to:

  • current police activity, a car chase, weapons drawn, drug raids;
  • gathering of people on the streets demonstrating threatening or intimidating behavior directed at the caseworker; and
  • illegal activities such as being close to the person’s home and occurring at the time the caseworker attempts the home visit.

When such situations occur and the caseworker feels threatened, they can make the home visit at another time. The caseworker must immediately notify regional management of their inability to conduct the home visit. The caseworker must schedule another service monitoring or annual reassessment visit at the earliest possible opportunity. The case must contain ongoing documentation of attempts to complete the visit and the reason for the delay until the monitoring visit has been completed.

If, during the home visit a person or someone in their home exhibits threatening behavior or makes comments that are threatening or hostile, the caseworker can end the service monitor or annual reassessment and reschedule for a later time. The caseworker must immediately notify regional management of their inability to conduct the home visit. The caseworker will refer to Section 2840, Threats to Health or Safety, to suspend or terminate services. If the threatening behavior is resolved, the caseworker must schedule another service monitoring or annual reassessment visit at the earliest possible opportunity. Document all attempts to complete the visit, along with any reasons for delays until the monitoring visit has been completed.

2840.2 Chronic Contagion or Infestation Conditions

Revision 24-5; Effective Nov. 1, 2024

While the chronic contagious medical condition or infestation of the person’s home may not pose an immediate danger to the health and safety of the person, provider agency staff or caseworker, either situation may adversely affect the health of all such people involved in supporting the person’s services and may pose a risk of exposing other people to the contagious medical condition or environmental infestation. Examples of unresolved chronic adverse medical or environmental related condition(s) may include the presence of bed bugs, fleas, ticks, lice or scabies.   
    
The caseworker must assess the person’s ability to comply with the request to eradicate contagions or infestations and should exhaust all efforts in arranging for help to eradicate contagions or infestations, based upon the assessment of the person’s capabilities. The caseworker should identify available local resources which may provide the needed help to meet the person’s specific needs for resolving the risks associated with the spread of the contagion or environmental infestation to others.

Per Section 2831, Suspensions Due to Refusal to Comply with Service Delivery Provisions, the provider or caseworker may suspend services until an interdisciplinary team (IDT) meeting is scheduled and the situation is discussed. Efforts to identify local resources and natural supports to help the person if any such resources and supports exist, should be well documented as part of the IDT meeting. Document any specific actions and responsibilities required of the person and other people and an agreed-upon time frame for completion of the eradication. Information from a pest control professional must be the basis in the establishment of a timeline expectation for eradication, as each situation is unique. The specific actions and responsibilities required of the person or other people, such as family members or friends, who have agreed to provide support as part of the eradication plan should be documented as service provision requirements.

If the eradiation plan is not followed and the situation is unresolved, the caseworker refers to Section 2830, Refusal to Comply with Service Delivery Provisions, and Section 2831 for guidance when the person is non-compliant with service delivery provisions.

The caseworker follows policy in 26 Texas Administrative Code Section 271.155, (f) Denial, Reduction or Terminations of Benefits, to provide adequate notice of possible termination of services if the person fails to cooperate with service delivery provisions.

2840.3 Active Tuberculosis (TB) Diagnosis

Revision 24-5; Effective Nov. 1, 2024

An applicant or person with a TB diagnosis cannot have services denied or terminated because of their disease.

The regional HHSC staff contacts their regional health department to ensure staff are linked to the right TB personnel to address TB cases on a case-by-case basis. The HHSC  caseworker may talk with their unit supervisor for help processing the case. They may use the Texas Department of State Health Services (DSHS) Public Health regions page to contact their regional health department. If the HHSC caseworker or supervisor cannot contact the local regional health department or needs more information, they may contact the DSHS TB and Hansen’s Disease Program staff linked to TB personnel in the county where the patient lives. The phone number is 512-533-3000 for general information and 512-533-3144 for the nurse administrator. Upon receiving the physician's report, DSHS assigns a representative to monitor the case through directly observed therapy. This process involves observation of the person taking their medication. It may also involve health-related training and the provision of more care of the person.

For cases with active TB, a team meeting should be set up to include the regional nurse, caseworker, provider and the local DSHS representative handling the case. These people ensure coordination of care and determine if special precautions need to be taken.

It is possible that DSHS will instruct HHSC to suspend the case while the TB remains active. If so, it will provide care for the person during this period. Most people become negative for TB within a few weeks of drug therapy.

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

2840.4 Sharing Information with New Providers Regarding Health and Safety Issues

Revision 24-5; Effective Nov 1, 2024

When services are suspended due to health and safety reasons, HHSC staff are required to convene an interdisciplinary team (IDT) meeting to resolve the issues. If the issues cannot be resolved, the provider may report it will no longer serve the person due to health and safety concerns.

In some situations, HHSC may terminate the person’s services due to health and safety issues. In other situations, HHSC may initiate services with a new provider. If the HHSC caseworker makes a referral to a new provider, they must determine how much information to share with the new provider about the previous actions.

The HHSC caseworker must share sufficient information with the new provider to avoid putting the provider at risk. This allows the provider to adequately plan for safely delivering services to the person, including selecting the appropriate service delivery staff and preparing the staff to handle situations that may arise. Providing information may avoid the issues that previously caused the termination or suspension.

Caseworkers must use good judgment to determine what information to share and, if in doubt, consult with their supervisors for guidance.

2841 Reinstatement of Services Terminated for Threats to Health or Safety

Revision 24-5; Effective Nov. 1, 2024

An applicant whose services were terminated in the past due to their or someone in their home being a threat to the health or safety of the client, department staff, or provider agency staff may be authorized services if the applicant signs Form H0003, Agreement to Release Your Facts, authorizing release of information, and:

(1) the applicant or person in home who posed the threat has been treated or is receiving treatment by a licensed or certified physician, psychiatrist, or psychologist and can furnish a letter saying that they are no longer a threat to themself or others;    
(2)the applicant or person in home allows a collateral contact with their physician, psychiatrist, or psychologist and the contact indicates that the applicant is no longer a threat to themself or others; or   
(3)the person in the home who posed the threat no longer poses the threat.

Complete the eligibility determination in the Service Authorization System Wizards within 30 calendar days after the date the signed application is received by the department. Review Section 2344,  Rights and Responsibilities.

2841.1 Sharing Information on Previous Actions for Reinstatement

Revision 24-5; Effective Nov. 1, 2024

If a person who is previously terminated from services due to health and safety reasons reapplies for services and meets the requirements in Section 2841, Reinstatement of Services Terminated for Threats to Health and Safety, information may need to be shared with a newly selected provider.

If the HHSC caseworker makes a referral to a new provider, they must determine how much information to share with the new provider about the previous actions that resulted in termination of services. The caseworker must share sufficient information with the new provider to avoid putting the provider at risk and allow the provider to adequately plan for safely delivering services to the person. This includes selecting the appropriate service delivery staff and preparing the staff to handle situations that may arise. Providing information may avoid the issues that previously caused the termination or suspension.

Caseworkers must use good judgment to determine what information to share and, if in doubt, consult with their supervisors for guidance.

2900, Appeals and Fair Hearings

2910 Individual’s Right to Appeal and Request a Fair Hearing

Revision 17-1; Effective March 15, 2017

40 Texas Administrative Code §48.3903

(a) An applicant or client may request an appeal of any decision that denies, reduces, or terminates his benefits.
(b) A client is entitled to be notified 10 days before any reduction or termination of his services, or to have the notification mailed 12 days before the date of reduction or termination. If a client threatens his own health or safety or that of others, purchased services may be terminated without advance notice.

Inform the applicant/individual in writing by sending Form 2065-A, Notification of Community Care Services, about his right to request a fair hearing if services are denied, reduced or terminated. An individual may appeal his dissatisfaction concerning

  • ineligibility for services;
  • the tasks within a service;
  • the amount (number of units) of service the individual will receive;
  • the amount of the copayment for Residential Care; or
  • the denial or termination of the priority status.

An individual also may appeal when the individual requests a new service, or requests an increase in the number of tasks or units of service, and the request is not acted on within required time limits.

To request a hearing, an individual may return Form 2065-A with a check mark in the appropriate box, or the individual may make an oral or written request for a fair hearing.

An individual must request a fair hearing within 90 days from the date of the action he wants to appeal. To continue receiving benefits until the hearings officer gives a decision, the individual must request the fair hearing before the effective date shown on Page 1 of Form 2065-A. In situations where services were terminated because of threats to the health or safety of another person, the individual is not entitled to continued services even if appealed before the effective date shown on Page 1 of Form 2065-A. (See Section 2811, Effective Dates, and Appendix IX, Notification/Effective Date of Decision, for guidance on effective date of termination in which the individual is not entitled to continued benefits.)

When a fair hearing is requested after the 90 day time period, HHSC staff may not prevent an applicant or individual from filing an appeal because they believe the appeal was not requested within the required number of days. If a fair hearing request is received after 90 days from the date of the notice, the case worker must follow current procedures to file the appeal. The hearings office will make the decision regarding the individual’s right to appeal.

The hearings officer is the final authority regarding the timeliness of appeal requests and accepts appeals filed after the time limit in order to determine whether there was good cause for the delay in filing.

2911 Notice to the Provider for Continuing Services

Revision 24-3; Effective July 1, 2024

If the person appeals before the effective date on Page 1 of Form 2065-A, Notification of Community Care Services, the caseworker must continue services at the current level pending the hearings officer’s decision unless denial is based on threats to health and safety. Review Section 2840, Threats to Health and Safety. The caseworker must complete a new Form 2101, Authorization for Community Care Services, in the Service Authorization System Online (SASO) reinstating services at the current level within three business days after receipt of the request for a fair hearing. The caseworker sends Form 2101 to the provider notifying them to provide services at the current level until the hearing officer’s decision is rendered. The Begin Date of services is the day after the termination date or reduction date on the previous Form 2101. The caseworker also sends Form 2067, Case Information, informing the provider to reinstate services pending the hearing officer’s decision.

Example 1: At the annual reassessment, the caseworker determines that the Primary Home Care personal attendant services (PAS) hours must be reduced from 20 to 15 hours per week. The caseworker sends Form 2065-A to the person and Form 2101 to the Home and Community Support Services Agency (HCSSA) as notification of the reduction in hours. The person appeals before the effective date of the case action. The caseworker authorizes PAS at 20 hours per week until the hearings officer’s decision is rendered.

When all services are terminated, such as at the annual reassessment when the person does not meet eligibility criteria, caseworkers must continue services at the current level when the person files an appeal before the effective date.

Example 2: At the annual reassessment, a Family Care person is terminated due to scoring 21 on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide. The caseworker sends Form 2065-A to the person and Form 2101 to the provider as notification of the termination of services. The person appeals before the effective date of the case action. The caseworker authorizes services at the same level as the previous Form 2101 authorization.

When the person submits a clear, written statement requesting services stop during the appeal process, the caseworker sends Form 2067 to the provider with an effective date to stop service delivery. The caseworker does not send the person another Form 2065-A.

HHSC does not continue services during the appeal process if Medicaid eligibility has been terminated unless Medicaid eligibility is reinstated during the appeal period. Refer to Section 3441, Loss of Categorical Status or Financial Eligibility, and Section 2932, Coordination of Fair Hearings with MEPD Utilizing OES CRU, for procedures related to Medicaid terminations and continuation of services.

2912 Special Procedures for Denials of Community Attendant Services (CAS) Individuals

Revision 17-1; Effective March 15, 2017

Denials of CAS individuals must be coordinated with both the HHSC regional nurse and with the Medicaid for the Elderly and People with Disabilities (MEPD) specialist. If the HHSC case worker denies the individual based on functional need, Form H1746-A, MEPD Referral Cover Sheet, must be sent to advise MEPD of the denial.

If the individual appeals the denial, another Form H1746-A must be sent to MEPD advising that services will be reinstated pending the fair hearings officer’s decision. MEPD must also be notified on Form H1746-A when a decision is rendered.

If the change that prompted the request for an appeal on a Community Attendant Services decision occurred in the course of an annual reassessment, use Form 2067, Case Information, to notify the provider and the HHSC regional nurse. The HHSC regional nurse submits Form 2101, Authorization for Community Care Services, to reinstate services.

2913 Coordinating with Utilization Review for Fair Hearing Requests as a Result of Utilization Review Findings

Revision 24-3; Effective July 1, 2024

HHSC caseworkers must notify the utilization review (UR) nurse and UR regional manager when an applicant or person has requested a fair hearing because of UR findings for concurrent reviews.

Caseworkers must follow normal time frames and procedures for implementing UR findings following receipt of a UR tool indicating a case action is required. When the action is completed for an addition or increase in services or termination or decrease in services, the caseworker must send a notice to the applicant or person notifying them of the case action. The applicant or person has the option to appeal the case action indicated on the notice. Caseworkers must follow current policies and procedures for continuation of services pending an appeal.

If the applicant or person requests a fair hearing, the caseworker must inform the UR nurse who completed the review and UR regional manager by email that a fair hearing has been requested because of the UR findings. The caseworker completes Form H4800, HHSC Fair Hearing Request Summary, and sends the form to the Hearing Division and supervisor within three days of the request for a hearing.

On Form H4800, the caseworker lists the UR nurse, Agency Representative, UR regional manager, and Agency Representative Supervisor. The caseworker may be listed. The caseworker must confirm the correct UR nurse and UR regional manager to list on the form. The caseworker includes the UR nurse whose name is in Section A of the UR tool. The caseworker identifies the name of the UR regional manager by calling the UR nurse or calling the Utilization Management and Review (UMR) manager identified on the UMR website.

The designated data entry representative (DER) is responsible for uploading the caseworker’s fair hearing evidence packet in the Texas Integrated Eligibility Redesign System (TIERS) Fair Hearings and Appeals system. The evidence packet submitted by the caseworker will include the applicable notification form. If available, the caseworker includes the signed notification form returned by the applicant or person. The caseworker does not include any other documentation in the evidence packet.

The UR nurse and UR regional manager develop the fair hearing evidence packet to support the decision made by UR to change the services planned or delivered to the applicant or person. The evidence packet includes a summary of the UR findings and applicable Texas Administrative Code (TAC) rules and policy. The UR representative will upload the evidence packet in TIERS.

Form H4800-A, Fair Hearing Request Summary (Addendum), must be included as the cover sheet for each fair hearing evidence packet. The DER and UR representative must upload the fair hearing evidence packets in TIERS no later than 10 calendar days before the fair hearing date. The caseworker and UR nurse must forward a copy of the fair hearing evidence packets to the applicant or person no later than 10 calendar days before the fair hearing date.

The UR nurse, UR regional manager (optional) and caseworker participate in the fair hearing to admit the fair hearing packets into evidence and provide testimony about the case action.

2913.1 Concurrent Utilization Review When a Fair Hearing is Pending or a Decision Has Been Rendered

Revision 24-3; Effective July 1, 2024

The caseworker must inform the Utilization Review (UR) nurse when a case record is selected for concurrent review and a fair hearing is pending. The caseworker does not submit the case record for concurrent review. UR will replace the case with another randomly selected case record for concurrent review.

The caseworker must inform the UR nurse of the fair hearing decision details when a case record is selected for concurrent review and a fair hearing decision has been rendered during the current plan year. They do this by providing the UR nurse with a copy of the final order submitted by the hearings officer. The caseworker must provide specific information to the UR nurse about the service(s) appealed and the actions the caseworker took to implement the hearings officer’s decision. The caseworker submits the case record for concurrent review following current procedures. The caseworker will follow current policy and procedures for implementing UR findings.

2914 Withdrawal of an Appeal

Revision 17-1; Effective March 15, 2017

An appellant or appellant representative may request to withdraw his appeal orally by calling the hearings office. An oral request to withdraw may be accepted by the hearings officer’s administrative assistant or the hearings officer. HHSC staff should advise the appellant or appellant representative to speak directly to the administrative assistant or hearings officer. If the appellant or appellant representative contacts HHSC staff regarding the withdrawal, HHSC staff must contact the hearings office via conference call with the appellant or appellant representative on the line so the appellant or appellant representative may inform the hearings office of the withdrawal. If the appellant or appellant representative sends a written request to withdraw to HHSC staff, HHSC staff must forward this written request to the hearings office. A fair hearing will not be dismissed based on an HHSC decision to change the adverse action. All requests to withdraw the hearing must originate from the appellant or appellant representative.

If the appellant or appellant representative requests to withdraw his appeal within 14 calendar days of the fair hearing date, the hearings officer will notify HHSC by phone or email and open the conference line to inform participants of the cancellation. If the appellant or appellant representative requests to withdraw his appeal more than 14 calendar days prior to the fair hearing date, the hearings officer will indicate the withdrawal in the Texas Integrated Eligibility Redesign System (TIERS) and a written notice will be sent to participants informing them of the fair hearing cancellation.

2920 Request for Increase in Services During an Appeal

Revision 17-1; Effective March 15, 2017

When services are reduced or terminated, such as at the annual reassessment, and the individual files an appeal before the effective date of the reduction or termination, the case worker must continue services at the current level until the hearings officer’s decision is rendered. If the individual requests increased services pending the hearings officer’s decision, the case worker cannot process the request. Within 14 calendar days of the request, the case worker must send the individual Form 2065-A, Notification of Community Care Services, explaining the request for increased services is denied pending the hearings officer’s decision and may be reviewed for authorization once the hearings officer’s decision is rendered, if the individual is determined eligible.

2930 Fair Hearing Procedures

Revision 17-1; Effective March 15, 2017

All fair hearings are processed through the Fair and Fraud Hearings section of the Appeals Division of the Texas Health and Human Services Commission (HHSC). The appeals division receives appeal requests from applicants and individuals contesting actions taken regarding benefits and services of various programs. These include the Supplemental Nutrition Assistance Program (formerly known as the Food Stamp Program), Temporary Assistance for Needy Families, all Medicaid-funded services, and other agency programs that are required by state or federal law, or rules, to provide the right to a fair hearing. Hearings officers conduct hearings, consider evidence and issue decisions in accordance with rules, regulations and state and federal law.

See the HHSC Fair and Fraud Hearings Handbook for specific information regarding the HHSC rules and requirements governing the fair hearings process.

2931 Processing Fair Hearing Requests Using TIERS

Revision 17-1; Effective March 15, 2017

When a request for a fair hearing is received from an applicant or individual orally or in writing, the Texas Health and Human Services Commission (HHSC) must refer the request to the hearings officer within five calendar days from the date of the request. Information is not mailed to the hearings officer, but is entered into the Texas Integrated Eligibility Redesign System (TIERS) Fair Hearings and Appeals system by the designated data entry representative.

Upon receipt of the fair hearing request, the case worker completes Form H4800,  Fair Hearing Request Summary.

The case worker sends Form H4800 to the Hearing Division and the supervisor within three calendar days of the request for a hearing. The three-day time frame allows the data entry representative two days to enter the information into the TIERS system. See the Form H4800 Instructions for specific directions for completion and transmittal.

Designated Data Entry Representative Procedures

Within two calendar days of receipt of Form H4800, the data entry representative enters the information into the Fair Hearings and Appeals system in TIERS. When the entry of all the information is completed, the system assigns the appeal identification (ID) number. The data entry representative will note the appeal ID number on the bottom of the form and in the designated space on the front of the form and send a copy back to the case worker and supervisor.

HHSC Fair Hearings and Appeals Procedures

The TIERS system will generate a hearing packet which includes Form H4803, Notice of Hearing, and Form H4800. The case worker and supervisor will receive a copy of Form H4800 and the letter identifying the hearings officer assigned and information on the time and location for the hearing. It is the supervisor's responsibility to ensure that the case worker or a designated representative participates in the hearing and is sufficiently prepared and knowledgeable about the case to represent the agency during the fair hearing process.

If Form H4800 has already been submitted into TIERS and there are subsequent changes such as address changes, participant updates, withdrawal forms or supporting documents needed for a fair hearing, the case worker completes Form H4800-A, Fair Hearing Request Summary (Addendum), with the updated information and submits it to the data entry representative.

The data entry representative must check TIERS for the fair hearings officer assigned to the case. If a fair hearings officer is not yet assigned, the data entry representative must wait until one is assigned to send the additional information. When sending information, the data entry representative completes the following activities according to the situation:

  • When Form H4800-A is completed informing the fair hearings officer of address changes, participant updates and withdrawal forms, the data entry representative sends Form H4800-A directly to the hearings officer’s email address. The case worker must enter the appeal ID number in the subject line.
  • When the data entry representative submits supporting documentation for an appeal, he uploads the information directly into TIERS and sends the hearings officer an email with Form H4800-A attached. The case worker must enter the appeal ID number in the subject line. The email must also inform the hearings officer that supporting documentation listed in Section 2 of Form H4800-A has been uploaded in TIERS. The case worker and data entry representative must follow current time frames and procedures to ensure supporting documentation is uploaded into TIERS no later than 10 calendar days prior to the fair hearing date.

2932 Coordination of Fair Hearings with Access and Eligibility Services, Integrity Support Services Appeals and Mitigation

Revision 24-4; Effective Sept. 1, 2024

Texas Health and Human Services Commission (HHSC) Access and Eligibility Services (AES), and Integrity Support Services Appeals and Mitigation (A&M) handles all hearings for Medicaid for the Elderly and People with Disabilities (MEPD) and Texas Works staff (TW). A&M replaces MEPD and TW staff in specific steps for denying AES applications and ongoing cases and:

  • represents HHSC AES in fair hearings;
  • completes and implements all AES case actions based on fair hearing decisions; and
  • coordinates required actions with AES staff and Community Care Eligibility Services (CCSE) staff.

The caseworker must coordinate all appeals with A&M, where AES staff determine financial eligibility. The caseworker must remember that A&M replaces AES staff in the following steps and to only send notices to AES staff if specified. All correspondence on appeals will go to the A&M supervisor and A&M administrative assistant.

People may appeal a decision verbally, in person or in writing. The caseworker must complete Form H4800, Fair Hearing Request Summary, to file the appeal through the Texas Integrated Eligibility Redesign System (TIERS) when a person requests a fair hearing. The method that the form is completed depends on the action being appealed. CCSE staff must determine if the appealed action is:

  • a CCSE service denial which are denials based on a CCSE denial action or
  • an AES financial denial which are denials based on an AES denial action.

If the appealed action is related to CCSE criteria other than an AES financial denial action, the caseworker completes Form H4800 and enters their name as the agency representative.

When the appealed action is an AES financial denial, the caseworker creates the appeal task in TIERS and A&M will process the appeal.

When the hearing officer renders a decision based on program criteria, the caseworker is notified by email of the decision. Based on the hearing decision, the caseworker determines the appropriate action per program specific time frames. The caseworker may need to coordinate an effective reinstatement date with A&M and must email the A&M mailbox. Per current procedures, the caseworker reports the implementation of the hearing decision through TIERS on Form H4807, Action Taken on Hearing Decision.

2933 Submitting the Appeals Evidence Packet

Revision 24-3; Effective July 1, 2024

When an applicant or person requests a fair hearing, the burden of proof to uphold the Texas Health and Human Services Commission (HHSC) decision rests with HHSC. The hearings officer is a neutral party and is restricted by law from presenting the agency's case. It is crucial that staff complete and organize all fair hearing packets to support the agency decision.

The Texas Integrated Eligibility Redesign System (TIERS) generates a hearing packet that includes Form H4803, Notice of Hearing, and Form H4800, Fair Hearing Request Summary. The caseworker and their supervisor receive a copy of Form H4800, the letter identifying the hearings officer assigned, and the time and location of the hearing. Staff or the designated representative participating in the hearing must be sufficiently prepared and knowledgeable about the case to represent the agency during the fair hearing process.

Each entity involved in the fair hearing is responsible for preparing its packet and forwarding the packet to both the:

  • hearings officer identified on Form H4800; and
  • appellant.

All documentation must be neatly and logically organized, and all pages numbered. Staff use Form H4800-A, Fair Hearing Request Summary (Addendum), to submit all supporting documentation to the hearings officer. The appeal identification number assigned by TIERS must be written on the top of Form H4800-A.

Provide the names, titles, addresses and phone numbers of all people or designees who will attend the hearing. Depending on the issue being appealed, the region may elect to send more staff such as the regional nurse or regional attorney. However, it is mandatory that the following staff attend:

  • Medicaid for the Elderly and People with Disabilities (MEPD) or Centralized Representation Unit (CRU), for financial denials;
  • caseworker or designee, for all case decisions; or
  • Utilization Review nurse to the appeal action, if applicable.

All related documentation necessary to support the agency's decision must be sent by the data entry representative (DER) to the fair hearings officer as soon as possible, but by 10 calendar days before the hearing. Examples of additional information and who is responsible for submitting that information to the state fair hearings officer and appellant include, but are not limited to:

  • the caseworker or designee:
    • Texas Administrative Code or policy handbook references about the case action;
    • summary of events;
    • a copy of any individual service plans, Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, or other official documentation forms including form instructions;
    • other documentation supportive of the decision, such as records of phone calls or visit summaries;
    • any relevant Utilization Review findings; and
    • a signed copy of the denial notification form and if available, use the signed form returned by the applicant or person when the appeal was filed;
  • MEPD:
    • documentation supportive of the financial decision, including official documentation forms and phone calls; and
    • a copy of the original signed denial form returned by the member, if available and if unavailable, send unsigned copy;

Uploading the Appeals Evidence Packet into TIERS

All evidence packets must be scanned into the TIERS Appeals application using the process described below. The regional data entry representative (DER) uses Form H4800-A to submit all supporting documentation, also referred to as the appeals packet, to the fair hearings officer. The appeal identification number assigned by TIERS must be written on the top of Form H4800-A. The DER must upload the fair hearing evidence packet in TIERS by 10 calendar days before the fair hearing date.

The caseworker must provide the information to the DER by 12 calendar days before the fair hearing date, to allow enough time for the evidence packet to be submitted on time. The caseworker must:

  • go to the multi-function HHSC Work Center and scan in the documentation;
  • save the document by either allowing the default document name or entering a name of the user's choosing;
  • retrieve the scanned document and attach it to an email; and
  • send the document to the regional DER.

By 10 calendar days before the fair hearing date, the caseworker must forward a copy of the fair hearing evidence packet to the applicant or person requesting the fair hearing.

Within two business days after receipt, the DER must:

  • save the attachment to the appropriate network drive, as assigned by regional management;
  • go into the TIERS portal without launching TIERS and select the Appeals tab;
  • ensure the appeal has been entered in TIERS, a requirement that must be met before the next step can be completed;
  • select Hearing Evidence Packets Upload and enter the appeal identification;
  • select Document Type: Agency Evidence Packet and note that items entered in any other selection will not be included in the evidence packet;
  • select Validate;
  • check the details to ensure the right person has been selected;
  • browse for the document; and
  • select Upload.

Users who make mistakes that cannot be reversed may contact the state office Document Maintenance manager to help correct the error and upload the appropriate information.

2934 Presentation of Evidence at the Fair Hearing

Revision 17-1; Effective March 15, 2017

Staff listed on Form H4800, Fair Hearing Request Summary, will receive Form H4803, Notice of Hearing, notifying participants when the hearing will be held. HHSC staff must adequately prepare both the fair hearing packet and presentation of evidence at the fair hearing. The burden of proof to uphold the agency's decision rests with the agency. The hearings officer is a neutral party and is restricted by law from presenting the agency's case.

Documentation contained in the fair hearing packet will not be considered in the decision unless the packet is offered into evidence. To accomplish this requirement, the agency representative must present the packet, ask that it be submitted as evidence and summarize what the packet contains.

Example: "I want to offer the following packet as evidence in the appeal filed on the behalf of Joe Smith. Pages 1-10 contain information relating to the completion of Form 2060, Needs Assessment Questionnaire and Task/Hour Guide. Pages 11-15 contain policy from the Community Care for Aged and Disabled Handbook, which relate directly to the issue in question. Pages 16-20 contain documents signed by the applicant related to individual rights. Page 21 contains Form 2065-A, Notification of Community Care Services, which was mailed to the applicant on March 2, 2010."

The hearings officer usually can only consider the specific information offered in evidence when making the hearing decision. For example, the case worker may clearly explain how the applicant must score 24 points on Form 2060 to be eligible for Primary Home Care. However, if documentation backing up that explanation (Handbook policy, Form 2060 Instructions and appropriate appendices) is not contained in the packet, the explanation will not be considered.

Oral testimony may be considered only if read into the record and if the appellant agrees to allow it.

The hearings officer will ask the appellant if he received the evidence packet. If not, the hearings officer will attempt to determine why. If no effort was made to send a packet to the appellant, the packet may not be admitted and the appropriate agency representative will have to read information into the record in order to have it considered.

The hearings officer will then ask for objections and allow all admissible documents into evidence. Any documents admitted by the hearings officer may be considered when a decision is rendered. Specific items of importance on a page or policy section must be emphasized as the case is presented to ensure the case has been clearly presented. If any documents are not admitted, the hearings officer will explain the reasons for excluding the material.

2935 Action Taken after the Hearing Decision

Revision 17-1; Effective March 15, 2017

 

2935.1 Action Taken on the Hearing Decision for Reductions

Revision 17-1; Effective March 15, 2017

After the hearing is held, the Texas Health and Human Services Commission (HHSC) hearings officer will send a decision letter, Form H4807, Action Taken on Hearing Decision, to the appellant and send copies to the case worker and the supervisor. If the HHSC decision is sustained, then the case worker takes the appropriate action. If services continued during the appeal period, then the case worker completes a new Form 2101, Authorization for Community Care Services, and sends it to the provider with the reduced service amounts. The action must be completed within 10 calendar days after the hearings officer’s decision. It is not necessary to send the individual another Form 2065-A, Notification of Community Care Services, since the individual has already been notified of the change.

If the hearings officer reverses the decision, the hearings officer also sends HHSC Form H4807 and specifies the corrective action to be taken and a 10-day time frame for the completion of the action. The case worker continues authorization at the higher level of services. The case worker sends the individual Form 2065-A showing the new level of services. A new Form 2101 is not required, since the provider is already delivering services at the higher level. The case worker actions required by the hearings officer must be reported back through the Texas Integrated Eligibility Redesign System (TIERS) within the 10-day time frame designated by the hearings officer. Form H4807 is no longer completed and mailed back to the hearings officer. All communication will be through TIERS.

2935.2 Action Taken after the Hearing Decision of Terminations

Revision 17-1; Effective March 15, 2017

Once the hearings officer’s decision is rendered and if the individual is determined eligible to continue receiving services, the case worker sends Form 2065-A, Notification of Community Care Services, to the individual to notify him that the hearings officer’s decision overturned the termination and his eligibility is continued. The case worker includes the following statement in the comments: “The hearings officer has overturned the termination decision and you have been determined eligible for continued services effective (the begin date).” The case worker sends the provider an updated Form 2101, Authorization of Community Care Services, reinstating services.

If the hearings officer sustains the termination decision and services were not continued, then no further case worker action is required on the case. If the hearings officer sustains the termination decision and services were continued, the case worker must terminate services in Service Authorization System and send the provider Form 2101 ending services within 10 calendar days after the hearings officer decision, or in accordance with instructions provided by the hearings officer. The case worker does not send another Form 2065-A to the individual to provide notification that the individual is not eligible based on the hearings officer’s decision. The case worker orally notifies the individual of the termination of services and the effective date and documents the contact in the case record.

2935.3 Fair Hearings Officer Orders a New Assessment

Revision 17-1; Effective March 15, 2017

If the hearings officer’s final decision orders completion of a new Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, the hearing is closed as a result of this ruling. The case worker must notify the individual of the results of the new assessment on Form 2065-A, Notification of Community Care Services. The individual may appeal the results of the new assessment. If the individual chooses to appeal, the case worker must indicate in Section 8, Summary of Agency Action of Form H4800, HHSC Action Taken on Hearing Decision, and also during the fair hearing that the new assessment was ordered from a previous fair hearing decision. If the individual requests an appeal of the new assessment, HHSC continues services until the second fair hearing decision is implemented.

2935.4 Reporting the Action Through TIERS

Revision 17-1; Effective March 15, 2017

The case worker completes Form H4807, Action Taken on Hearing Decision, recording case actions taken and sends it to the supervisor and the designated data entry representative. The case worker must send Form H4807 within the time frames to allow at least two days for the data entry representative to enter the information into the system. If the action cannot be taken by the time frame designated by the hearings officer, the case worker must complete Section B on Form H4807 and send to the supervisor and data entry representative providing the reason for the delay. Acceptable reasons are listed on the form and the begin delay date and end delay date must be included. See the form instructions for detailed information on completing Form H4807.

2936 Fair Hearing Exception Process

Revision 24-3; Effective July 1, 2024

Staff must implement the decision of the fair hearings officer within the applicable time frames when a fair hearing decision is rendered. This includes the restoration of any benefits or services.

Staff who disagree with the result of a fair hearing must follow regional procedures in referring the issue to the regional director. Staff use Form 1590, Request for a Fair Hearing Exception, to initiate a fair hearing exception request. The form documents the region's request for a review of a fair hearing decision.

If they agree with the region's request, the regional director forwards Form 1590 to the Community Services Policy (CSP) unit manager. The CSP unit manager must receive the form by the fifth calendar day following the date on the hearing decision. A copy of the form is kept in regional files, not in the case record.

Once the region's exception request is reviewed, the CSP unit manager decides whether to forward it to HHSC for consideration. If the CSP unit manager or designee:

  • concurs with the regional assertion that policy was misapplied and forward the form to the Fair and Fraud Hearings Section.
  • determines a clear error of law or fact was made by the hearings officer and they request that HHSC review the case action and, if they agree, issue a revised hearing decision.
  • does not concur with the regional request and the request is not forwarded to HHSC.

If the CSP unit manager forwards the exception request for consideration by HHSC, then the HHSC caseworker or designee must mail Form 1015 or Form 1015-S, Fair Hearing Exception Letter, and a copy of the exception request to the applicant or person. The caseworker or designee must place the letter and exception request in the outgoing mail by the close of the next business day following receipt of the notification from the CSP unit manager. A copy of the letter and exception request must be placed in the case record.

The region will be notified of the decision if the request was or was not forwarded to HHSC. Even if an exception request is being filed, the hearings officer's decision must be implemented within the required time frames.