Community Living Assistance and Support Services (CLASS) Provider Manual

1000, Introduction

Revision 17-1; Effective November 1, 2017

The Community Living Assistance and Support Services (CLASS) program provides home and community-based services to people with related conditions as defined in Texas Administrative Code (TAC), Chapter 45, Subchapter A, §45.104. The CLASS program is funded by Title XIX Medicaid through a federal waiver that provides the opportunity for the Texas Health and Human Services Commission (HHSC) to offer specialized services that are not available under the regular Medicaid program. Individuals who receive CLASS program services may not also receive services from a program included in Appendix III, HHSC Operated Program CLASS Mutually Exclusive Services.

HHSC supports the expectation that every person has the opportunity to participate in their community, gain and maintain relationships of their choosing, express preferences, make choices, fulfill goals, and live with dignity and respect. The fundamental framework for delivering program services to individuals is based on tailoring program services to the individual's needs and circumstances. Services offered in the CLASS program supplement, but do not supplant, other Medicaid services, generic services, and other family and community supports to assist individuals successfully live and work in the community.

The goal of the CLASS program is to support individuals with related conditions to achieve their desired lifestyles and to be valued members of the community by:

  • addressing health and safety;
  • offering opportunities to better achieve their goals; and
  • making the most efficient use of all available resources to accomplish these goals.

CLASS program services must:

  • protect the individual's health and welfare in the community;
  • address the individual's related condition;
  • not be available to the individual through any other source, including Medicaid state plan, other governmental programs, private insurance or the individual's natural supports;
  • prevent the individual's admission to an institution;
  • be the most appropriate type and amount to meet the individual's needs; and
  • be cost effective.

HHSC obtains Medicaid provider agreements with qualified provider agencies to deliver CLASS program services. The case management agency (CMA) provides case management services and the direct services agency (DSA) provides all other CLASS services, except Support Family Services (SFS), Transition Assistance Services (TAS) and Consumer Directed Services (CDS) delivery options. All provider agencies must work cooperatively to ensure that the individual's needs are met.

Rules governing the CLASS program are in Title 40 of the Texas Administrative Code (TAC), Chapter 45.

1100, Complaints and Consumer Rights and Services (CRS)

Revision 17-1; Effective November 1, 2017

When to Call HHS CRS

CRS receives complaints from individuals, family members, providers and the public about the care, treatment or services provided to an individual. Individuals receiving services or family members of the individual may prefer to call CRS to assist in resolving an issue rather than speaking with their case manager or DSA representative.

A complaint may be reported by anyone at any time to CRS by calling 1-800-458-9858. A complaint may be made online at crscomplaints@dads.state.tx.us.

Information about CRS can also be located on the HHS website at https://hhs.texas.gov/about-hhs/your-rights/consumer-rights-services/how-do-i-make-a-complaint-about-hhs-service-provider.

Written complaints may be mailed to:

Texas Department of Health and Human Services
Consumer Rights and Services, Mail Code E-249
P.O. Box 149030
Austin, TX 78714

CRS Website

The CRS website provides useful information regarding filing a complaint; locating consumer rights booklets; reporting abuse, neglect and exploitation; and locating community services. Visit the website at https://hhs.texas.gov/about-hhs/your-rights/consumer-rights-services.

Provider Agency Complaint Process

The CLASS provider agencies are required to have processes for receiving and resolving complaints about the provision of CLASS services. The process by which a complaint may be filed with a CLASS provider agency regarding CLASS program services must be provided to the individual/legally authorized representative (LAR) at the time of enrollment and at least annually thereafter.

1200, Interest List

Revision 17-1;  Effective November 1, 2017

HHSC manages the capacity of the program in accordance with available funding and within federally approved program limits by offering enrollment to individuals registered on the interest list. Individuals interested in receiving services in the CLASS program must register via the CLASS interest list. Individuals may register on the CLASS interest list regardless of whether they meet program eligibility requirements and must participate in financial and functional eligibility assessments as part of the enrollment process. Individuals registered on the CLASS interest list must ensure current address and contact information is on file with HHSC/DADS.

If an applicant is denied waiver enrollment based on diagnosis, level of care, or other functional eligibility requirements, HHSC will place the applicant’s name on all other waiver program’s interest list, using the applicant’s original request date for the CLASS interest list.

To contact the CLASS interest list call 877-438-5658.

1300, CLASS Program Eligibility

Revision 17-1; Effective November 1, 2017

HHSC approves eligibility for the CLASS program for applicants/individuals with related conditions who meet all of the following eligibility requirements.

  • The individual is financially eligible for Medicaid because the individual receives Supplemental Security Income (SSI) cash benefits or HHSC determines the individual  to be financially eligible for Medicaid.
  • HHSC determines the individual meets the diagnostic/functional eligibility criteria for the CLASS program — Intermediate Care Facility for Persons with Intellectual Disability (ICF/ID) Level of Care VIII criteria.
  • The individual has been diagnosed prior to age 22 with a related condition as described in the Texas Approved Diagnostic Codes for Persons with Related Conditions.
  • The individual has a qualifying adaptive behavior level of II, III or IV (i.e., moderate to extreme deficits in adaptive behavior) obtained by administering the Inventory for Client and Agency Planning (ICAP), Vineland Adaptive Behavior Scales, Second Edition (Vineland-II), Scales of Independent Behavior – Revised (SIB-R), or American Association of Intellectual and Developmental Disabilities (AAIDD) Adaptive Behavior Scales (ABS).
  • The individual exhibits a substantial functional limitation in at least three of the following areas of major life activities as documented on the Related Conditions Eligibility Screening Instrument:
    • learning;
    • mobility;
    • self-care;
    • language;
    • self-direction (age 10 and over); and
    • independent living (age 10 and over).
  • The individual demonstrates a need for Community First Choice (CFC) PAS/HAB.
  • The individual requires and receives at least one CLASS Program service per month, and one CLASS service per year (monthly monitoring of services by a case manager meets this requirement).
  • The individual has an Individual Plan of Care (IPC) cost for CLASS program services at or below $114,736.07.
  • The individual is not enrolled in another Medicaid waiver program.
  • The individual resides in his or her own home or family home.

2100, Case Management Responsibilities

Revision 17-1; Effective November 1, 2017

Case management services are provided to all individuals receiving Community Living Assistance and Support Services (CLASS) program and Community First Choice (CFC) Personal Assistance Services/Habilitation (PAS/HAB) services in the CLASS program.  Individuals must select a CMA with a valid provider agreement in the catchment area in which the individual lives. Individuals who receive services in the CLASS program may request to transfer to another CMA at any time.

As outlined in this section, the CMA is required to provide the following case management services on an ongoing basis:

  • assist the individual as necessary to maintain Medicaid eligibility;
  • conduct various tasks related to enrollment;
  • perform functions related to service planning;
  • provide technical assistance to individuals using the Consumer Directed Services (CDS) service delivery option when completing Form 3596, PAS/Habilitation Plan - CLASS/DBMD/CFC ;
  • monitor the provision of CLASS services;
  • protect the individual's rights;
  • intervene to assist individuals in crisis; and
  • coordinate the individual's CLASS services with non-CLASS services as necessary through the employment of person-centered planning techniques.

CLASS program services, as a whole, enhance an individual's integration into the community and prevent admission to an institution while maintaining and improving independent functioning.

2110 Base of Operation

Revision 11-3; Effective November 18, 2011

CLASS program providers must have a base of operation that includes a physical location and normal operating hours in each geographic catchment area for which they have a contract to provide CLASS program services.

  1. A base of operation is a place in which business, clerical or professional activities are conducted. Each base of operation must:
    • maintain individual records for the CLASS program contract in the catchment area;
    • maintain personnel records for personnel who provide CLASS program services to individuals served in the catchment area;
    • be staffed by qualified employees who have completed CLASS program training and can readily become familiar with the individuals being served in the catchment area; and
    • maintain adequate staff to provide services and to supervise the provision of services within the catchment area.
  2. Providers must identify the base of operation's normal operating hours. If the base of operations is closed during its normal operating hours or between the hours of 8:00 a.m. and 5:00 p.m. Monday through Friday, the provider must:
    • post a notice in a visible location outside the base of operations to provide information regarding how to contact the person in charge; and
    • leave a message on an answering machine or similar electronic mechanism to provide information regarding how to contact the person in charge.
    •  

2120 CMA Staff Training Requirement

Revision 12-1; Effective January 13, 2012

2121 Initial Training for Staff with Direct Contact

Revision 17-1; Effective November 1, 2017

Direct contact for the purposes of this manual means face to face contact. Upon hire, all CMA staff whose job functions might involve direct contact a minimum of one time per calendar year with individuals receiving Community Living Assistance and Support Services (CLASS) must complete one of the following within 60 calendar days of the employee beginning to provide CLASS program services:

  • In-person CLASS provider training provided by the Texas Health and Human Services (HHSC).
  • Training developed by CMA that includes, at a minimum:
    • CLASS program overview;
      • person-centered planning;
      • philosophy and values of community integration;
      • overview of related conditions and CLASS program eligibility criteria;
      • service planning team (SPT) process;
      • utilization review process;
      • consumer directed services; and
      • individuals' rights and responsibilities including:
        • fair hearing process;
        • CMA's complaints process;
        • mandatory participation requirements; and
        • abuse, neglect and exploitation characteristics and reporting information.

The CMA could choose to conduct training at its location to meet the above requirements within 60 days of hiring the service provider. CMA staff who develop the curriculum used for initial training must have attended and successfully completed the CLASS Provider Training provided by HHSC. The CMA must have a record to verify that the trainer has attended the CLASS Provider Training. The CMA may choose to send new employees to CLASS Provider Training at the next opportunity offered by HHSC to further reinforce training provided by the CMA.

Documentation of completion of required training must include, at a minimum:

  • CLASS Provider Training completion certificate with the name of the employee, signed by HHSC; or
  • written documentation of completion of CMA's training that includes:
    • training topics covered;
    • method of training (i.e., reading, video, discussion, etc.);
    • name(s) and qualifications of instructor(s);
    • name of the trainee;
    • date the training was completed;
    • signature and date of the instructor(s); and
    • signature and date of the trainee verifying completion.

If a CMA develops curriculum to meet CLASS training requirements, the curriculum and training materials used must be maintained by CMA and be available to HHS employees during a contract monitoring review.

2122 Initial and Annual Training for All CMA Staff

Revision 17-1; Effective November 1, 2017

All CMA staff must complete the training described below within 60 calendar days of employment and at least every 12 months thereafter.

  • Abuse, Neglect and Exploitation (ANE)
  • Rights and Responsibilities of Individuals
    • information about the rights of the individual who receives CLASS services as outlined in the Your Rights in these Community Programs; and
    • review of CLASS rules in Chapter 45, Subchapter C, §45.301 and §45.302 concerning the Rights and Responsibilities of an Individual.

If a CMA develops curriculum to meet CLASS training requirements, the curriculum and training materials used must be maintained by CMA and available to HHSC employees during a contract monitoring review.

2123 CMA Staff Training for Person-Centered Planning

Revision 17-1; Effective November 1, 2017

CMA staff responsible for completing Form 8606, Individual Program Plan (IPP) and Form 3629 Individual Program Plan Addendum (IPP-A) must complete person-centered service planning training approved by HHSC depending upon the staff date of hire. If the staff person was hired on or before June 1, 2015, the staff must complete the training by June 1, 2017. If the staff person was hired after June 1, 2015, the staff person must complete the training within two years after the hire date.

2200, Eligibility

Revision 17-1; Effective November 1, 2017

The case manager is responsible for verifying the individual's eligibility for the CLASS program by ensuring the following criteria are met.

  • The individual is financially eligible for Medicaid because the individual receives Supplemental Security Income (SSI) cash benefits or is determined by HHS to be financially eligible for Medicaid.
  • The individual has been diagnosed prior to age 22 with a related condition as described in the Texas Approved Diagnostic Codes for Persons with Related Conditions.
  • The individual has a qualifying adaptive behavior level of II, III, or IV (i.e., moderate to extreme deficits in adaptive behavior) obtained by administering a standardized assessment of adaptive behavior.
  • The individual demonstrates a need for CFC PAS/HAB;
  • The individual requires and receives:
    • at least one CLASS service per month; and
    • one CLASS service per year (monthly monitoring of services by a case manager meets this annual requirement).
  • The individual has an Individual Plan of Care (IPC) cost for CLASS services at or below $114,736.07.
  • The individual is not enrolled in another Medicaid waiver program.
  • The individual resides in his or her own home or family home.

The CMA must verify Medicaid eligibility each month by monitoring the Medicaid Eligibility Service Authorization Verification (MESAV) system. The Medicaid eligibility must verify the individual is eligible in the month that is being checked. Documentation of this monthly verification of eligibility for Medicaid must be maintained by the CMA and available for review during contract monitoring visits. If the CMA receives notice of an individual's impending loss of Medicaid eligibility, the CMA must work proactively with the individual/legally authorized representative (LAR) to ensure Medicaid eligibility is re-established as soon as possible. For individuals who lose Medicaid eligibility, the CMA must offer direct assistance to the individual/LAR as necessary to help the individual re-establish eligibility. The CMA must follow up with the individual/LAR at least every two weeks and document progress toward completion of necessary steps until Medicaid eligibility is re-established or the individual is terminated from the CLASS program.

Program services may be terminated if the individual does not meet any eligibility criteria as outlined in Title 40 of the Texas Administrative Code (TAC) §45.406. See Section 2400, Denial, Reduction, Suspension and Termination, for more information on termination of services.

2300, Service Planning

Revision 17-1; Effective November 1, 2017

The case manager facilitates Service Planning Team (SPT) meetings. The SPT process uses a person-centered planning processes to develop a plan for the provision of supports and services necessary for the individual's functioning and to maintain integration in the community. After all requirements for eligibility are met, and at least annually thereafter, the case manager, the applicant/individual/legally authorized representative (LAR), DSA representative(s) (as defined in Section 3300, Service Planning), and other people requested by the applicant/individual/LAR meet to develop a proposed Form 3621, CLASS/CFC – Individual Plan of Care (IPC). The case manager must use the SPT notes in conjunction with Form 3629, IPP-A to document use of person-centered planning processes.

The case manager, using the discovery process as the basis for collecting information, develops the person-centered plan with the individual, legally authorized representative (LAR), the CMA, DSA representative, and others, as requested by the individual or LAR.

Examples of the discovery process include, but are not limited to:

  • information about the person gained from engaging in conversations with the individual, LAR and those who know the individual best, such as a provider staff, caregiver, family member and friend;
  • utilizing the Planning Alternative Tomorrows with Hope (PATH) method;
  • utilizing methods taught by The Learning Community for Person Centered Practices (TLCPCP), which occur with the support of a group of people chosen by the individual (and the legally authorized representative (LAR) on the individual's behalf).

The person-centered planning process:

  • accommodates the individual's style of interaction, communication and preferences regarding time and setting;
  • identifies the individual’s strengths, preferences, support needs and desired outcomes;
  • identifies what is important to the individual;
  • identifies and document the individual’s current and preferred living arrangement;
  • determines the service needs of an individual;
  • assesses the individual's needs, functional impairments, ability to perform activities of daily living (ADLs), instrumental activities of daily living (IADLs) and health-related tasks;
  • identifies natural supports available to the individual and needed service system supports;
  • documents the individual’s preferences for when to receive CLASS services;
  • documents the risks to the individual’s health and safety, as well as a plan to mitigate those risks;
  • identifies any special needs, requests or considerations staff should know when supporting this individual; and
  • documents the individual’s unmet needs.

Additional guidance and information about person-centered planning can be found on the HHSC website.

Meetings of the SPT to develop the enrollment IPC and the renewal IPC should be held in the individual’s own home or family home whenever possible. If it is not possible, the SPT must document why the meeting could not be held in the individual’s home. While individuals or their LAR may request the case manager meet in locations other than their own home/family home, case managers should remind them that meeting in the home allows the SPT the opportunity to determine if other needs of the individual may be met by through CLASS or CFC services. The enrollment and renewal IPC must be signed in person by the SPT.

SPT activities to revise a current IPC may occur via conference call in lieu of a face-to-face meeting. Revisions of the current service plan may be signed by facsimile.

The case manager is required to ensure that the SPT develops a transportation plan if habilitation transportation is included on the IPC. Information on completing Form 3598, Individual Transportation Plan is available in the instructions.

The proposed IPC must specify:

  • the type of CLASS program services to be provided to the individual;
  • the number of units of each CLASS program service;
  • the number of units of each CFC service (except support management)
  • the estimated annual cost of all CLASS program and CFC services; and
  • other services or supports to be provided to the individual through sources other than the CLASS program.

As part of the service planning process, the SPT will also develop an IPP on Form 8606, Individual Program Plan (IPP).

An IPP is needed for each CLASS program service listed on the proposed IPC. Each IPP describes:

  • CLASS program services to be provided;
  • frequency of service provisions;
  • observable and measurable goals and objectives;
  • title of person responsible for goals and objectives;
  • justification for services based on needs identified by the SPT;
  • duration of services; and
  • support services provided through non-waiver resources.

The IPP-A and SPT notes are created by the case manager during the SPT meeting to document use of person-centered planning processes. The IPP-A and SPT notes summarize the outcome of the meeting and must be included with the IPP-A to provide additional information. The SPT notes must include, at a minimum:

  • each service being requested by the SPT;
  • planned service schedules for each service requested;
  • units/amount of each service requested; and
  • signature and date of each SPT member present at the meeting.

If the individual requests a therapeutic service (e.g., occupational therapy, physical therapy, speech and language pathology, behavioral support, audiology, dietary service, auditory enhancement training or any specialized therapy), the case manager must initiate Form 8606-A, Therapy Justifications – Attachment to IPP, based on the deliberations of the SPT. The case manager must coordinate the completion of Attachment A with the appropriate professional. Since this professional is employed by, or contracts with, the DSA, assistance from the DSA is vital to ensure the case manager performs this function. The signature date of the professional on Attachment A may precede the effective date of the IPC that identifies the individual’s need for the service or continuation of the need for the service by no more than 120 days.

The case manager is responsible for initiating revisions to the individual's IPC and IPP-A as determined necessary throughout each plan year. The case manager will submit all proposed IPCs and revised IPP-A to HHSC.

On an ongoing basis, the case manager must assist individuals in gaining access to needed CLASS services and other services and supports, including medical, social, and educational resources, regardless of the funding source for the services and supports.

All requests from HHSC related to the UR process must be submitted within the period outlined in Section 5000.

The CMA is responsible for providing a copy of the following documentation to all SPT members within 10 business days from HHSC authorization, including the financial management services agency (FMSA), if the individual receives a service through the Consumer Directed Services option:

  • authorized Form 3621, CLASS/CFC — Individual Plan of Care;
  • Form 3629, Individual Program Plan Addendum;
  • Form 8606, Individual Program Plan (IPP);
  • SPT notes;
  • Form 8606-A, Therapy Justifications — Attachment to IPP, if applicable;
  • Form 3660, Request for Adaptive Aids, Medical Supplies, Minor Home Modifications or Dental Services/Sedation, if applicable; and
  • additional documentation as agreed upon by the SPT.

2310 Enrollment

Revision 19-4; Effective November 8, 2019

At the time an applicant receives a written offer of a CLASS program vacancy from HHSC, the applicant must select a CMA within 30 calendar days after the date of the written offer. HHSC notifies the selected CMA the applicant has chosen the agency to provide case management services. According to the Selection Determination document the CMA then completes the following:

  • Form 3657, Pre-Enrollment Assessment;
  • Form 8507, Understanding Program Eligibility - CLASS/DBMD;
  • assists the applicant with the application process for Medicaid eligibility, if needed; and
  • provides general information regarding the CLASS Medicaid waiver program to CLASS applicants.

The case manager must provide the applicant/individual the CLASS Program brochures in English or Spanish, as appropriate.

The case manager should take advantage of this opportunity to describe the person-centered planning process, as described in Section 2300, that will be used to develop the IPP-A.

Upon notification that the applicant has selected the CMA, a case manager must be assigned to the applicant. The CMA must have a written process that ensures case managers are or can readily become familiar with individuals to whom they are not ordinarily assigned, but to whom they may be required to provide case management.

The case manager must complete the following functions within 14 calendar days of the CMA's receipt of the Selection Determination document from HHSC:

  • provide applicant/legally authorized representative (LAR) with name and contact information, including an alternate contact in case of absence of the case manager;
  • conduct an initial face-to-face, in-home visit with the applicant/LAR that must include providing an oral and written explanation of:
    • CLASS program services;
    • CFC services available in the CLASS program through the Medicaid State Plan;
    • CFC personal assistance services/habilitation (CFC PAS/HAB), which provides all the activities of habilitation, except habilitation transportation services;
    • CFC emergency response services (CFC ERS), which is provided as a CFC service;
    •  CFC support management;
    • the eligibility requirements for CLASS Program services and CFC services using Form 8507, Understanding Program Eligibility- CLASS/DBMD;
    • the mandatory participation requirements;
    • the CDS option;
    • the complaint process;
    • information about cognitive rehabilitation therapy (CRT) and assistance for the individual to obtain a neurobehavioral or neuropsychological assessment and plan of care from a qualified professional using Medicaid State Plan, if appropriate;
    • Form 8601, Verification of Freedom of Choice, specifying choice of CLASS services instead of institutional services in an Intermediate Care Facilities for Individuals with an Intellectual Disability or Related Conditions (ICF/IID);
    • provide information regarding voter registration, if the applicant is age 18 or older;
    • if the applicant is transferring from an institution, provide information regarding Transition Assistance Services (TAS):
      • ensuring the proper information is included on Form 8604, Transition Assistance Services (TAS) Assessment and Authorization;
      • sending the completed form to HHSC for authorization with the proposed enrollment IPC;
      • sending the authorized form to the TAS provider; and
      • including the TAS and the monetary amount authorized by HHSC on the individual's proposed enrollment IPC;
    • provide an oral and written explanation to the applicant/LAR describing that the DSA may be requested to provide CFC PAS/HAB or out-of-home respite in a camp while the individual is temporarily staying outside the catchment area in which the individual resides, but within the state of Texas, as described in 40 TAC §45.702 , including that the DSA may accept or decline the request;
      • provide the following information regarding required use of the Electronic Visit Verification (EVV):
      • EVV will not change the services the individual receives.
      • EVV helps HHSC make sure authorized services are received.
      • EVV is mandatory for all DSAs and individuals receiving services from a CFC PAS/HAB services provider, unless the individual receives services through the CDS
      • The CFC PAS/HAB services provider will need the applicant’s permission to use the telephone to call a toll-free number at the start and at the end of work.
      • If the applicant does not have a telephone or does not want the CFC PAS/HAB services provider to use his telephone, a fixed verification device can be placed in the home, which is used only to verify the CFC PAS/HAB services provider’s start and end of work.
      • EVV is mandatory for all DSAs and applicants who will be receiving services from a CFC PAS/HAB services provider, unless the applicant elects to receive services through the CDS option.
      • Failure to cooperate will result in the suspension or termination of services.
      • If the applicant has additional questions, the case manager refers him to the selected DSA or FMSA for additional information on how EVV works;
    • complete Form 3657; and
    • verify residency to ensure the applicant lives in his own or family home that is located within the catchment area for which the CMA has a current Community Services Contract (Provider Agreement), to provide CLASS program services.

The case manager must complete the following functions within two business days following the initial face-to-face assessment:

  • evaluate the applicant's need for CFC PAS/HAB services;
  • assist with Medicaid eligibility processes, as necessary;
  • verify the individual is not enrolled in another 1915(c) Medicaid waiver program or any other mutually exclusive services or programs (See Appendix III, Mutually Exclusive Services); and
  • provide the DSA with a completed Form 3657.

Within 30 calendar days of notification by the DSA of HHSC approval of diagnostic/functional eligibility for an individual as identified on Form 8578, Intellectual Disability/Related Condition Assessment, the case manager must convene the SPT to develop the enrollment IPC, Form 3621, CLASS/CFC – Individual Plan of Care (IPC) and Form 3629, Individual Program Plan Addendum using a person-centered planning process as described in Section 2300.

The SPT must include, at a minimum, the applicant/LAR, case manager and a DSA representative. The individual or LAR may request the SPT include professionals who are qualified by certification or licensure, or training and experience in the habilitation needs of people with related conditions, or directly involved in the delivery of services and supports to the individual. The SPT may include any other people requested by the individual/LAR. The SPT must make every effort to accommodate these requests by the individual/LAR.

Within 10 business days of HHSC transmission of the authorized enrollment IPC, as evidenced by the fax transmittal date on the documents, the case manager must provide copies of the authorized Form 3621, Form 8606, Form 3629, the SPT notes, Form 8606-A (if applicable), Form 3660 (if applicable), and additional documentation as agreed upon by the SPT to all members of the SPT. The case manager must provide copies of this documentation to any additional CLASS service providers (FMSA, Continued Family Services [CFS], and Support Family Services [SFS]), as necessary. The case manager must maintain documentation of transmission of all necessary documents.

Form Resources

The following forms may need to be completed as part of the enrollment process:

  • Form 1351, Request to Withdraw from the CLASS Application Process
  • Form 1581, Consumer Directed Services Option Overview
  • Form 1582, Consumer Directed Services Responsibilities
  • Form 1583, Employee Qualification Requirements
  • Form 1584, Consumer Participation Choice
  • Form 1740, Service Backup Plan
  • Form 2067, Case Information
  • Form 3596, PAS/Habilitation Plan — CLASS/DBMD/CFC
  • Form 3598, Individual Transportation Plan
  • Form 3621, CLASS/CFC — Individual Plan of Care
  • Form 3623, Approval of Application for CLASS
  • Form 3625, CLASS/CFC — Documentation of Services Delivered
  • Form 3628, Provider Agency Model Service Backup Plan
  • Form 3629, Individual Program Plan Addendum
  • Form 3657, Pre-Enrollment Assessment
  • Form 4800-D, DADS Fair Hearing Request Summary
  • Form 8001, Medicaid Estate Recovery Program Receipt Acknowledgement
  • Form 8507, Understanding Program Eligibility - CLASS/DBMD
  • Form 8598, Non-Waiver Services
  • Form 8601, Verification of Freedom of Choice
  • Form 8604, Transition Assistance Services (TAS) Assessment and Authorization
  • Form 8606, Individual Program Plan (IPP)
  • Form H1010, Texas Works Application for Assistance – Your Texas Benefits
  • Form H1200, Application for Assistance – Your Texas Benefits
  • Form H1350, Opportunity to Register to Vote
  • Form H3034, Disability Determination Socio-Economic Report
  • Form H3035, Medical Information Release/Disability Determination

Submission Standard — Enrollment

The following submission standards apply when submitting enrollment paperwork to HHSC:

  • Choice Lists for the CLASS Program
  • Form 3596, PAS/Habilitation Plan - CLASS/DBMD/CFC
  • Form 3598, Individual Transportation Plan (only include if this specific service has been proposed as part of an enrollment IPC)
  • Form 3621, CLASS/CFC – Individual Plan of Care
  • Form 3629, Individual Program Plan Addendum
  • Form 3660, Request for Adaptive Aids, Medical Supplies, Minor Home Modifications or Dental Services/Sedation (only include if this specific service has been proposed as part of an enrollment IPC)
  • Form 3849-A, Specifications for Adaptive Aids/Medical Supplies/Minor Home Modifications, including bids (only include if funding for specifications has been proposed as part of an enrollment IPC)
  • Form 6515, CLASS/DBMD Nursing Assessment
  • Form 8578, Intellectual Disability/Related Condition Assessment
  • Form 8598, Non-Waiver Services
  • Form 8601, Verification of Freedom of Choice
  • Form 8604, Transition Assistance Services (TAS) Assessment and Authorization (only include if this specific service has been proposed as part of an enrollment/renewal IPC)
  • Form 8606, Individual Program Plan (IPP)
  • Form 8606-A, Therapy Justifications – Attachment to IPP (only include if this specific service has been proposed as part of an enrollment IPC)

Submission Standard — Pre-enrollment

The following submission standards apply when submitting paperwork containing funding proposals for pre-enrollment efforts to HHSC:

  • Form 3625, CLASS/CFC – Documentation of Services Delivered;
  • Form 3657, Pre-Enrollment Assessment (partial assessment fee); or
  • Form 3621, CLASS/CFC – Individual Plan of Care (full assessment fee)

2320 Renewal

Revision 17-1; Effective November 1, 2017

The case manager must complete the following functions no less than 30 calendar days and no more than 90 calendar days before the end of the current IPC year:

  • provide an oral and written explanation to the individual/legally authorized representative (LAR) describing that the DSA) may be requested to provide CFC PAS/HAB or out-of-home respite in a camp while the individual is temporarily staying outside the catchment area in which the individual resides, but within the state of Texas. The service period cannot exceed 60 consecutive days. The case manager must provide the information contained in 40 TAC §45.702 regarding this option, including the DSA option to accept or decline the individual’s request;
  • provide information about cognitive rehabilitation therapy (CRT) and assistance for the individual to obtain a neurobehavioral or neuropsychological assessment and plan of care from a qualified professional using Medicaid State Plan, if appropriate;
  • provide Form 8601, Verification of Freedom of Choice, specifying the individual’s choice to continue to receive CLASS services instead of ICF/IID and obtain the individual’s signature;
  • convene a SPT to develop using person-centered planning processes:
    • a renewal IPC – the CLASS program services on the proposed renewal IPC must meet the following standards:
      • are necessary to protect the individual's health and welfare in the community;
      • address the individual's related condition;
      • are not available to the individual through any other source, including the Medicaid State Plan, other governmental programs, private insurance or the individual's natural supports;
      • prevent the individual's admission to an institution;
      • are the most appropriate type and amount of CLASS program services to meet the individual's needs; and
      • are cost effective;
    • a renewal IPP for each service proposed on the renewal IPC;
    • the IPPA; and
    • a CFC PAS/Habilitation Plan;
  • submit to HHS:
    • Form 3629, Individual Program Plan Addendum;
    • Form 3621, CLASS/CFC — Individual Plan of Care;
    • Form 8606, Individual Program Plan (IPP); the SPT notes;
    • Form 8606-A, Therapy Justifications — Attachment to IPP, if applicable;
    • Form 3660, Request for Adaptive Aids, Medical Supplies, Minor Home Modifications or Dental Services/Sedation, if applicable; and
    • additional documentation as agreed upon by the SPT for review; and
  • submit a copy of the proposed renewal IPC to the FMSA, if applicable.

Within 10 business days of HHSC transmission of the authorized renewal IPC, as evidenced by the fax transmittal date on the documents, the case manager must provide copies of the authorized Form 3621, Form 8606, Form 3629, the SPT notes, Form 8606-A (if applicable), Form 3660 (if applicable), and additional documentation as agreed upon by the SPT to all members of the SPT. The case manager must provide copies of this documentation to any additional CLASS service providers (FMSA, Continued Family Services [CFS], and Support Family Services [SFS]) as necessary. The case manager must maintain documentation of transmission of all necessary documents.

The CMA must electronically access MESAV to verify that the services authorized on the renewal IPC are consistent with those authorized in MESAV by HHSC.

At HHSC's request, the CMA must submit additional documentation supporting the proposed renewal IPC to HHSC within 10 calendar days after HHSC requests it. The date of HHSC’s request for additional documentation is determined by the date on Form 2067, Case Information, faxed to the CMA that requests the additional documentation.

If HHSC notifies the CMA of the denial or reduction of a CLASS program or CFC service, see Section 2400, Denial, Reduction, Suspension and Termination.

Form Resources

The following forms may need to be completed as part of the renewal process:

Submission Standard

The following submission standards apply when submitting renewal paperwork to DADS:

  • Choice Lists for the CLASS Program
  • Form 3596, PAS/Habilitation Plan — CLASS/DBMD/CFC
  • Form 3598, Individual Transportation Plan (only include if this specific service has been proposed as part of a renewal IPC)
  • Form 3621, CLASS/CFC — Individual Plan of Care
  • Form 3629, Individual Program Plan Addendum
  • Form 3660, Request for Adaptive Aids, Medical Supplies, Minor Home Modifications or Dental Services/Sedation (only include if this specific service has been proposed as part of a renewal IPC)
  • Form 3849-A, Specifications for Adaptive Aids/Medical Supplies/Minor Home Modifications, including bids (only include Form 3849-A if funding for specifications has been proposed as part of a renewal IPC)
  • Form 6515, CLASS/DBMD Nursing Assessment
  • Form 8578, Intellectual Disability/Related Condition Assessment (ID/RC)
  • Form 8598, Non-Waiver Services
  • Form 8601, Verification of Freedom of Choice
  • Form 8606, Individual Program Plan (IPP)
  • Form 8606-A, Therapy Justifications – Attachment to IPP (only include if this specific service has been proposed as part of a renewal IPC)

2330 Revision

Revision 17-1; Effective November 1, 2017

When the case manager is notified of a needed revision to the IPC, the case manager must ensure:

  • a proposed IPC revision includes:
    • an IPP for each service revised on the proposed IPC;
    • a revised Form 3629, Individual Program Plan Addendum, if applicable; and
    • a revised PAS/Habilitation Plan - CLASS/DBMD/CFC, if the individual’s needs have changed substantially since the most recent revision;
  • the CLASS program services on the proposed IPC revision must meet the following standards:
    • are necessary to protect the individual's health and welfare in the community;
    • address the individual's related condition;
    • are not available to the individual through any other source including the Medicaid state plan, other governmental programs, private insurance or the individual's natural supports;
    • prevent the individual's admission to an institution;
    • are the most appropriate type and amount of CLASS program services to meet the individual's needs;
    • are cost effective; and
  • the proposed IPC, IPP-A, IPPs, and PAS/Habilitation Plan - CLASS/DBMD/CFC are submitted to HHSC for review at least 30 calendar days before the effective date proposed by the SPT.

At the request of HHSC, the CMA must submit additional documentation supporting the proposed IPC revision to HHSC within 10 calendar days after HHSC requests it. The date of HHSC’s request for additional documentation is determined by the date on Form 2067, Case Information, faxed to the CMA that requests the additional documentation.

If HHSC notifies the CMA of the denial or reduction of a CLASS program or CFC service, see Section 2400, Denial, Reduction, Suspension and Termination.

Within five business days of HHSC’s transmission of the authorized IPC, as evidenced by the fax transmittal date on the documents, the case manager must provide copies of the following to all members of the SPT:

  • Form 3621, CLASS/CFC — Individual Plan of Care;
  • Form 8606, Individual Program Plan (IPP);
  • Form 3629, Individual Program Plan Addendum,
  • the SPT notes;
  • Form 8606-A, Therapy Justifications — Attachment to IPP, if applicable;
  • Form 3660, Request for Adaptive Aids, Medical Supplies, Minor Home Modifications or Dental Services/Sedation, if applicable; and
  • additional documentation as agreed upon by the SPT.

The case manager must also provide copies of the above documentation within five business days of HHSC’s transmission of the authorized IPC to any additional CLASS service providers (FMSACFS, and SFS), as necessary. The case manager must maintain documentation of transmission of all necessary documents.

The CMA must electronically access MESAV to verify that the services authorized on the renewal IPC are consistent with those authorized in MESAV by HHSC.

Submission Standard

The following submission standards apply when submitting revision paperwork to HHSC:

  • Form 3596, PAS/Habilitation Plan – CLASS/DBMD/CFC (only include if this specific service has been proposed as part of an IPC revision marked "New" or "Change" in Field 16a on Form 3621)
  • Form 3598, Individual Transportation Plan (only include if this specific service has been proposed as part of an IPC revision marked "New" or "Change" in Field 16a on Form 3621)
  • Form 3621, CLASS/CFC – Individual Plan of Care
  • Form 3629, Individual Program Plan Addendum
  • Form 3660, Request for Adaptive Aids, Medical Supplies, Minor Home Modifications or Dental Services/Sedation (only include if this specific service has been proposed as part of an IPC revision marked "New" or "Change" in Field 16a on Form 3621)
  • Form 3849-A, Specifications for Adaptive Aids/Medical Supplies/Minor Home Modifications, including bids (only include if funding for specifications has been proposed as part of an IPC revision)
  • Form 6515, CLASS/DBMD Nursing Assessment
  • Form 8598, Non-Waiver Services
  • Form 8606, Individual Program Plan (IPP) (only include if this specific service has been proposed as part of an IPC revision marked "New" or "Change" in Field 16a on Form 3621)
  • Form 8606-A, Therapy Justifications – Attachment to IPP (only include if this specific service has been proposed as part of an IPC revision marked "New" or "Change" in Field 16a on Form 3621)

2331 Immediate Jeopardy of CLASS Individual

Revision 17-1; Effective November 1, 2017

When the CMA receives written documentation from the DSA indicating the DSA provided CFC PAS/HAB, respite, nursing, dental services or an adaptive aid that is not included on the individual's IPC in response to a situation of the individual's immediate jeopardy, the case manager must complete and submit the following to HHSC:

  • a proposed IPC revision;
  • revised IPP-A, if appropriate;
  • revised Individual Program Plans (IPPs); and
  • documentation to HHSC within seven calendar days of notification by the DSA.

For the above, the CMA must use the date which the DSA RN documented determination the individual was subject to immediate jeopardy without the provision of additional CFC PAS/HAB, respite, nursing, dental services, or an adaptive aid that is not included on the individual's IPC as the IPC revision effective date.

The documentation furnished to the CMA by the DSA must include:

  • a description of circumstances necessitating the provision of the new service or the increase in the amount of the existing service; and
  • documentation by a registered nurse of the nurse's determination the service was necessary to prevent the individual's health and safety from being placed in immediate jeopardy.

HHSC authorizes the IPC only if, after reviewing the documentation, HHSC determines the service was necessary to prevent the individual's health and safety from being placed in immediate jeopardy.

At HHSC request, the CMA must submit additional documentation supporting the proposed IPC revision to HHSC within 10 calendar days.

Form Resources

The following forms may need to be completed as part of the revision process:

2340 Transfer

Revision 17-1; Effective November 1, 2017

When the individual/legally authorized representative (LAR) notifies the case manager they wish to be transferred to a different agency(s), the case manager must:

  • document in the individual's IPP-A the date the transfer request was received;
  • provide the individual/LAR with the most current choice list document for the applicable catchment area;
  • within three business days, make transfer arrangements with the individual/LAR, the receiving CMA DSA or FMSA, as appropriate;
  • establish an effective date for the individual's transfer that is at least 14 calendar days after the date of receiving notice of intent to transfer; and
  • coordinate with the agencies involved in the transfer to determine the number of needed service units for each authorized service code.

The current CMA must submit the following to HHSC before the effective date of the transfer:

Form Resources

The following forms may need to be completed as part of the transfer process:

Submission Standard

The following submission standards apply when submitting transfer paperwork to HHS:

2350 IPP Service Review

Revision 17-1; Effective November 1, 2017

The case manager is responsible for ongoing monitoring of:

  • the provision of CLASS program and CFC services; and
  • the status of non-CLASS program services and supports.

The case manager must meet with the individual or LAR in the individual's home, or other location if services are not primarily provided in the individual’s home, to review the IPC and update the IPP-A if needed. CMA Individual Program Plan (IPP) service reviews will occur in accordance with the schedule in Appendix X, IPP Service Summary/IPP Service Review Due Dates Chart, from the effective date of the most recent enrollment or renewal IPC. The fourth IPP service review of the IPC year is combined with the meeting of the SPT to develop a renewal IPC. The IPP-A and SPT notes will document the development of the renewal IPC using person-centered planning processes. The case manager must use Form 3595, IPP Service Review, to document the review of the services delivered to the individual since the ninth month IPP service review.

The purpose of meeting the individual or LAR in the setting where services are delivered is to allow the case manager to verify that services listed on the IPC are delivered as described in the Individual Program Plan (IPP). This function is best accomplished by the case manager observing CLASS services in the setting in which they are provided. Since most individuals receive CLASS services in the home setting, the IPP service reviews should occur in the location where the majority of services are delivered.

While individuals or their LAR may request the case manager meet in locations other than their own home/family home, case managers should remind them that a complete assessment of services provided to the individual is required to be performed in the setting in which those services are delivered. Case managers must document when and why an individual or LAR refuses to meet in the home setting in the “General Comments” section of Form 3595.

During the IPP service review face-to-face contact with the individual, the case manager must complete Form 3595 to:

  • review the services received as documented on the IPC;
  • document progress or lack of progress toward goals/objectives as identified on the IPP/IPC;
  • assess the individual's satisfaction with the provision of CLASS program services;
  • determine if the service backup plan was implemented and if it met the needs of the individual; and
  • identify any changes to the individual's needs to include any needed revisions to the service backup plan.

The case manager is required to complete all sections of Form 3595 for CLASS services provided to an individual. The case manager may choose to print only those pages that reflect the services reviewed and provide them to the individual, the DSA and any additional CLASS service providers (FMSACFS, and SFS), as necessary.

If an individual's IPC includes any nursing services or CFC PAS/HAB, and any of those services are not currently identified as requiring a service backup plan, the case manager must discuss with the individual or LAR whether any of those services may now be critical to the individual's health and safety. If the case manager and individual/LAR determines either service may now be critical to the individual's health and safety, the case manager must convene the SPT to discuss development of a service backup plan.

The case manager must also ask the individual/LAR if a service backup plan was implemented during the most recent review period and discuss the implementation of the service backup plan with the individual/LAR to determine whether or not the plan was effective.

If the service backup plan was implemented and determined to be ineffective, the case manager must convene an SPT meeting to revise the service backup plan.

If a change is requested by the individual during the IPP service review, the case manager is responsible for initiating any change(s) needed and convenes the SPT, as applicable within five business days after becoming aware that the individual's needs have changed. The case manager must also update the IPP-A.

Within five business days of the IPP service review, the case manager is responsible for providing copies of the service review with the updated IPP-A to the individual, DSA and any additional CLASS service providers (FMSACFS, and SFS), as necessary. The case manager must maintain documentation of transmission of all necessary documents.

Form Resources

The following forms may need to be completed as part of the 90-day service review:

2400, Denial, Reduction, Suspension and Termination

Revision 17-1; Effective November 1, 2017

An individual whose CLASS program or CFC services are denied, reduced, suspended or terminated must be given notice of adverse actions taken by HHSC and is entitled to a fair hearing.

The CMA must obtain written authorization from HHSC for all suspensions of CLASS program or CFC services.

HHSC issues a notice to the CMA of all denials of enrollment or terminations from the CLASS program. The CMA must notify the individual, DSA, FMSA, CFS and SFS provider as applicable.

Program services may be terminated if the individual does not comply with the conditions as outlined in 40 TAC §45.406 or violates any of the conditions specified in 40 TAC §45.408. Program services may also be terminated if an individual does not comply with 40 TAC §45.407, or exhibits behavior that places the health and safety of the CMA's case manager or a DSA's service provider in immediate jeopardy as described in 40 TAC §45.409.

2410 Denial

Revision 17-1; Effective November 1, 2017

Denial is a HHSC action that disallows:

  • an individual's request for enrollment in the CLASS program;
  • a service requested on the IPC that was not authorized on the prior IPC; or
  • a portion of the amount or level of the service requested on the IPC that was not authorized on the prior IPC.

Denial of a Request for Enrollment into the CLASS Program

HHSC denies an individual's request for enrollment into the CLASS program if:

  • the individual does not meet the eligibility criteria described in §45.201, Eligibility Criteria; or
  • the DSAs serving the catchment area in which the individual resides are not willing to provide CLASS program services to the individual because they have determined that they cannot ensure the individual's health and safety.

If HHSC denies a request for enrollment, HHSC sends a written notice to the individual or LAR of the denial of the individual's request for enrollment into the CLASS program and includes in the notice the individual's right to request a fair hearing in accordance with 40 TAC §45.301, Individual's Right to a Fair Hearing. HHSC sends a copy of the written notice to the individual's DSA, CMA and, if selected, FMSA.

Denial of a CLASS Program Service

HHSC denies a CLASS program service on an individual's IPC if services:

  • are not necessary to protect the individual's health and welfare in the community;
  • do not address the individual's related condition;
  • are available to the individual through any other source including the Medicaid State Plan, other governmental programs, private insurance or the individual's natural supports;
  • do not prevent the individual's admission to an institution;
  • are not the most appropriate type and amount of CLASS program and CFC services to meet the individual's needs; or
  • are not cost effective.

If HHSC denies a CLASS program or CFC service on an individual's IPC, HHSC notifies the CMA in writing. Upon receipt of HHSC written notice of denial of a CLASS program or CFC service, the CMA must send Form 3624, Termination, Reduction or Denial of CLASS, to the individual/LAR of the denial of the service, copying the individual's DSA and, if selected, FMSA, CFS or SFS provider.

Form Resources

The following forms may need to be completed as part of a suspension denial of services:

Submission Standard

The following submission standards apply when submitting a request for an appeal to HHSC:

  • Form 3624, Termination, Reduction or Denial of CLASS
  • Written documentation established by the CMA in the event of a verbal request for appeal by individual/LAR (only if individual/LAR did not exercise their appeal rights using Form 3624)
  • Form 4800-D, Fair Hearing Request Summary
  • Form 4800-DA, 4800-D Addendum (only if there are more than three other hearing participants who require notification of a hearing)

2420 Reduction

Revision 17-1; Effective November 1, 2017

Reduction is an HHSC action taken because of a review of an IPC that decreases the amount or level of a service authorized by HHSC on an IPC.

HHSC will perform utilization review on all IPCs that meet criteria outlined in Section 5000, Utilization Review (UR). All services and units of service included on a proposed IPC must be justified by the SPT.

HHSC CLASS Program staff review the IPC to ensure the services on the IPC:

  • are necessary to protect the individual's health and welfare in the community;
  • supplement rather than replace the individual's natural supports and other non-CLASS program services and supports for which the individual may be eligible;
  • prevent the individual's admission to an institution;
  • are the most appropriate type and amount of services to meet the individual's needs; and
  • are cost effective.

The case manager has the responsibility to gather the following information for the HHSC CLASS program staff:

  • assessments;
  • reports;
  • professional observations; or
  • other resources.

The case manager must summarize this information using the appropriate IPP.

As necessary during the review of a proposed IPC, HHSC CLASS program staff will ask case managers to provide additional justification if the initial information submitted with a proposed IPC is not sufficient to demonstrate the need for requested services or does not meet requirements for a CLASS IPC as outlined in Section 1000, Introduction. If information submitted to HHSC by the case manager does not provide sufficient information to justify requested units of services, HHSC will modify the IPC by reducing the number of units of services as necessary and will send the CMA a copy of the modified IPC.

If an individual's services are reduced, the CMA must notify the individual and provide a copy of the notification to the DSA, FMSA and Support Family Services provider, as applicable, of the documentation of the reason for the reduction. Upon receipt of a written notice proposing to reduce a service, the CMA must inform the individual or LAR of the HHSC decision. The CMA informs the individual of the right to request a fair hearing.

The case manager sends written notice on Form 3624, Termination, Reduction or Denial of CLASS, to the individual allowing 12 days for the participant individual to respond before taking any action to reduce services.

If the individual or LAR requests a fair hearing before the effective date of the reduction of a CLASS program service, as specified in the written notice, the DSA must provide the service to the individual in the amount authorized in the prior IPC while the appeal is pending.

Form Resources

The following forms may need to be completed as part of a suspension reduction of services:

Submission Standard

The following submission standards apply when submitting a request for an appeal to HHSC:

  • Form 3624, Termination, Reduction or Denial of CLASS
  • Written documentation established by the CMA in the event of a verbal request for appeal by individual/LAR (only if individual/LAR did not exercise their appeal rights using Form 3624)
  • Form 4800-D, Fair Hearing Request Summary
  • Form 4800-DA, 4800-D Addendum (only if there are more than three other hearing participants who require notification of a hearing)

2430 Suspension

Revision 17- 1; Effective November 1, 2017

Individuals may not receive CLASS program or CFC services during a period of time in which they are admitted to a facility listed in this section. Individuals must be suspended without prior notification from CLASS program or CFC services until such time as the individual returns to his own or family home or is terminated from the CLASS program. The individual is not eligible for continuation of CLASS program or CFC services until the fair hearing process is completed because suspension of an individual's services is effective the date the individual was temporarily admitted to one of the facilities listed below, or leaves the state and, therefore, the individual is not given advance notice of the suspension.

Within two business days after the CMA becomes aware of a situation that necessitates an individual's CLASS program or CFC services to be suspended, the CMA must send a written request for suspension with written supporting documentation to HHSC CLASS program staff.

HHSC notifies the individual's CMA in writing of whether it authorizes a suspension of CLASS program or CFC services. Suspension is a HHSC action taken:

  • upon an individual's admission for any length of time up to 180 consecutive calendar days to one of the following facilities:
    • an ICF/IID licensed or subject to being licensed in accordance with Texas Health and Safety Code, Chapter 252, or certified by HHSC, unless the individual is receiving out-of-home respite in the facility;
    • a nursing facility licensed or subject to being licensed in accordance with Texas Health and Safety Code, Chapter 242, unless the individual is receiving out-of-home respite in the facility;
    • an assisted living facility licensed or subject to being licensed in accordance with Texas Health and Safety Code, Chapter 247;
    • a residential child-care operation licensed or subject to being licensed by the Texas Department of Family and Protective Services (DFPS), unless it is a foster family home or a foster group home;
    • a facility licensed or subject to being licensed by the Texas Department of State Health Services (DSHS);
    • a facility operated by HHSC; or
    • a residential facility operated by the Texas Youth Commission, a jail or prison; or
  • upon an individual leaving the state for up to 180 consecutive calendar days, except when an individual is receiving certain services available through the CDS option while the individual is temporarily staying at a location outside the state of Texas. For more details, see Information Letter No. 16-35, Receiving Services Outside the State of Texas in the CLASS and DBMD Programs.

Upon receipt of a written notice from HHSC authorizing the suspension of CLASS program or CFC services, the CMA must send the written notice of suspension to the individual/ LAR, DSA and FMSA, if applicable. The written notice includes the individual's right to request a fair hearing. The period of suspension is the length of the admission to the facility or the time spent in another state. An individual may remain on suspension from CLASS program or CFC services for up to 180 calendar days. HHSC may extend an individual's suspension for 30 calendar days upon the CMA's request.

Form Resources

The following forms may need to be completed as part of a suspension of services:

Submission Standard

The following submission standards apply when submitting a request for an appeal to HHSC:

  • Form 3624, Termination, Reduction or Denial of CLASS
  • Written documentation established by the CMA in the event of a verbal request for appeal by individual/LAR (only if individual/LAR did not exercise their appeal rights using Form 3624)
  • Form 4800-D, Fair Hearing Request Summary
  • Form 4800-DA, 4800-D Addendum (only if there are more than three other hearing participants who require notification of a hearing)

2440 Termination

Revision 17-1; Effective November 1 , 2017

Termination is a HHSC action that results in the loss of the individual's authorized services in the CLASS program and CFC.

2441 Termination With Advanced Notice

Revision 17- 1; Effective November 1, 2017

HHSC terminates an individual's CLASS program and CFC services if:

  • the individual does not meet program eligibility criteria;
  • the individual is admitted for more than 180 consecutive calendar days to one of the following facilities:
    • an ICF/IID licensed or subject to being licensed in accordance with Texas Health and Safety Code, Chapter 252 or certified by HHSC, unless the individual is receiving out-of-home respite in the facility;
    • a nursing facility licensed or subject to being licensed in accordance with Texas Health and Safety Code, Chapter 242, unless the individual is receiving out-of-home respite in the facility;
    • an assisted living facility licensed or subject to being licensed in accordance with Texas Health and Safety Code, Chapter 247;
    • a residential child-care operation licensed or subject to being licensed by DFPS , unless it is a foster family home or a foster group home;
    • a facility licensed or subject to being licensed by DSHS ;
    • a facility operated by HHSC;
    • a residential facility operated by the Texas Juvenile Justice Department, a jail or prison; or
  • the individual leaves the state for more than 180 consecutive calendar days and HHSC has not extended the individual's suspension;
  • DSAs serving the catchment area in which the individual resides are not willing to provide CLASS program and CFC services to the individual because they have determined that they cannot ensure the individual's health and safety; or
  • the individual refuses to comply with a mandatory participation requirement as follows:
    • not completing and submitting an application for Medicaid financial eligibility to HHSC within 30 calendar days after the case manager's initial face-to-face, in-home visit. (Note: If an individual or LAR does not submit a Medicaid application to HHSC within 30 calendar days of the case manager's initial face-to-face, in-home visit as required but is making good faith efforts to complete the application, the CMA may extend this time frame in 30 calendar-day increments as approved by HHSC CLASS program staff.);
    • not participating with the SPT to:
      • develop an enrollment IPC;
      • develop, renew, or revise an IPP-A;
      • renew and revise the IPC and IPPs;
    • not reviewing, agreeing to, signing and dating an IPC, IPP-A, and IPPs;
    • not using natural supports and other non-CLASS program or CFC services and supports for which the individual may be eligible before using CLASS program services;
    • not cooperating with the CMA and DSA in the delivery of CLASS program and CFC services listed on the individual's IPC, including:
      • working with the CMA and DSA in scheduling meetings;
      • attending scheduled meetings with the case manager or service provider;
      • being available to receive the CLASS program or CFC services;
      • notifying the CMA or DSA in advance if the individual or LAR is unable to attend a scheduled meeting or is unavailable to receive services in the individual's own or family home;
      • admitting CMA and DSA representatives to the individual's own home or family home for a scheduled meeting or to receive CLASS program and CFC services;
    • not cooperating with the CLASS program or CFC service providers to ensure progress toward achieving the goals and objectives described in the IPP for each CLASS program or CFC service listed on the IPC;
    • not paying a required copayment in a timely manner when found by HHSC to be financially eligible for CLASS program and CFC services based on the special institutional income limit;
    • not completing the procedures for redetermining eligibility for Medicaid, as described in the Medicaid for the Elderly and People with Disabilities Handbook;
    • engaging in criminal behavior in the presence of the case manager or CLASS program or CFC service provider;
    • permitting a person present in the individual's own or family home to engage in criminal behavior in the presence of the service provider or case manager;
    • acting in a manner that is threatening to the health and safety of the case manager or CLASS program or CFC service provider;
    • permitting a person present in the individual's own or family home to act in a manner that is threatening to the health and safety of the case manager or CLASS program or CFC service provider;
    • exhibiting behavior or permitting a person present in the individual's residence to exhibit behavior that places the health and safety of the case manager or CLASS program or CFC service provider in immediate jeopardy;
    • initiating or participating in fraudulent health care practices;
    • engaging in behavior that endangers the individual's health or safety; and
    • permitting a person present in the individual's own home or family home to engage in behavior that endangers the individual's health or safety.

If termination of services is requested based on a determination by the DSA that it cannot ensure the individual's health and safety, the CMA must include in the request specific reason(s) why the DSA determines it cannot ensure the individual's health and safety.

Prior to termination of services, an individual may choose another DSA. The CMA must provide the most current selection determination document in catchment areas with multiple DSAs. If another DSA determines the individual’s medical and nursing needs can be adequately met, the CMA must initiate a transfer IPC as described in Section 2340 of the CLASS Provider Manual.

HHSC notifies the individual's CMA in writing using Form 3624, Termination, Reduction or Denial of CLASS, or written notice from HHSC, of whether it authorizes the proposed termination of CLASS program and CFC services.

Upon receipt of HHSC notification authorizing a proposed termination of CLASS program services, the CMA must send written notice of the termination of CLASS program and CFC services to the individual or LAR within two business days. The CMA must send a copy of the termination notice to the individual's DSA and, if selected, FMSA, CFS and SFS provider. The CMA must include in the notice the individual's right to request a fair hearing.

In the event CLASS program services are terminated due to an individual's IPC cost being over $114,736.07, HHSC sends written notice to the individual or LAR of the proposal to terminate CLASS program services and includes the individual's right to request a fair hearing in the notice. HHSC sends a copy of the written notice to the individual's DSA, CMA, and if selected, FMSA.

If a CMA becomes aware an individual has not complied with a mandatory participation requirement described in this section, the CMA must immediately attempt to resolve the situation, including facilitating at least one face-to-face meeting with the SPT. If, after making attempts to resolve the situation, the CMA determines that the situation cannot be resolved, the CMA must request in writing that HHSC terminate CLASS program services for the individual. The request must be sent to HHSC within two business days of the CMA's determination the situation cannot be resolved and be supported by written documentation. The written documentation must include a description of:

  • the situation that resulted in the request to terminate CLASS program and CFC services; and
  • the attempts by the CMA and DSA to resolve the situation, including face-to-face meetings with the individual or LAR.

If an individual's CLASS Program services and CFC services are terminated, the CMA must ensure that the case manager informs the individual of alternative long-term care services and supports in the community. The explanation must include advising the individual about receiving CFC services through a managed care organization and institutional services, such as an ICF/IID. More information can be located on the Texas Health and Human Services website.

The CMA will not provide notice of a termination of CLASS program and CFC services to an individual for whom HHSC has terminated due to an IPC cost being over $114,736.07. HHSC will provide notice to individuals in this situation directly.

If the individual or LAR requests a fair hearing before the effective date of a proposed termination of CLASS program services, the DSA must provide services to the individual in the amounts authorized in the IPC while the appeal is pending.

2442 Termination Without Advanced Notice

Revision 17- 1; Effective November 1, 2017

HHSC terminates an individual's CLASS program services without advanced notice if any of the following situations exist:

  • the CMA or DSA has factual information confirming the death of the individual;
  • the CMA or DSA receives a clearly written statement signed by the individual that the individual no longer wishes to receive CLASS program services;
  • the individual's whereabouts are unknown and the post office returns mail directed to him or her by the CMA or DSA, indicating no forwarding address;
  • the CMA or DSA establishes the individual has been accepted for Medicaid services by another state; or
  • an individual or a person in the individual's residence exhibits behavior that places the health and safety of the CMA's case manager or a DSA's service provider in immediate jeopardy. See Section 2443, Immediate Jeopardy of CLASS Providers.

Within two business days after the CMA becomes aware of a situation such as described above, the CMA must send a written request to terminate CLASS program and CFC services to HHSC. The written request must be accompanied by documentation supporting the request.

If an individual's CLASS Program services and CFC services are terminated, the case manager must document attempts to inform the individual of alternative long-term care services and supports in the community. The explanation must include advising the individual about receiving CFC services through a managed care organization and institutional services, such as an ICF/IID. More information can be located on the Texas Health and Human Services website at https://hhs.texas.gov/.

HHSC notifies the individual's CMA in writing of whether it authorizes the termination of CLASS program services. Upon receipt of a written notice from HHSC authorizing the termination of CLASS program services, the CMA must send written notice to the individual or LAR of the termination. The CMA must also send a hard copy of the termination notice to the individual's DSA and, if selected, FMSA, CFS and SFS provider. The CMA must include in the notice the individual's right to request a fair hearing.

2443 Immediate Jeopardy of CLASS Providers

Revision 17-1; Effective November 1, 2017

HHSC may terminate an individual's CLASS program services if an individual or a person in the individual's residence exhibits behavior that places the health and safety of the CMA's case manager or a DSA's service provider in immediate jeopardy.

If a CMA or DSA becomes aware a situation exists that places the health and safety of the individual's case manager, CLASS program or CFC service provider in immediate jeopardy, the CMA or DSA must:

  • immediately file a report with the appropriate law enforcement agency and, if appropriate, make an immediate referral to DFPS; and
  • notify HHSC, CMA and DSA by telephone of the situation no later than one business day after the CMA or DSA becomes aware of the situation.

The CMA and DSA must attempt to resolve the situation. If, after making attempts to resolve the situation, the CMA determines that the situation cannot be resolved, the CMA must, within two business days after the CMA becomes aware of the situation, send a written request to terminate CLASS program and CFC services to HHSC. The written request must be accompanied by:

  • a description of the situation that resulted in the request to terminate the individual's CLASS program and CFC services;
  • a detailed description of the attempts by the CMA to resolve the situation; and
  • if available, a copy of any report issued by a law enforcement agency or DFPS regarding the situation.

HHSC notifies the individual's CMA in writing of whether it authorizes the proposed termination of CLASS program services.

Upon receipt of written notice from HHSC authorizing the termination of CLASS program services, the CMA must, no later than the date of the termination of services, send written notice to the individual or LAR of such termination. The CMA must provide a hard copy of the termination notice to the individual's DSA and, if selected, FMSA, CFS and SFS provider. The CMA must include in the notice the individual's right to request a fair hearing.

If an individual's CLASS Program services and CFC services are terminated, the case manager must document attempts to inform the individual of alternative long-term care services and supports in the community. The explanation must include advising the individual about receiving CFC services through a managed care organization and institutional services, such as an ICF/IID. More information can be located on the HHS website.

The CMA and DSA must maintain documentation of completion of these requirements in the individual's record.

Form Resources

The following forms may need to be completed as part of termination of services:

Submission Standard — Termination

The following submission standards apply when submitting termination paperwork to HHSC:

  • Form 3621, CLASS/CFC – Individual Plan of Care
  • Form 3624, Termination, Reduction or Denial of CLASS
  • Documentation of circumstances that support the termination of CLASS services.

Submission Standard — Appeal

The following submission standards apply when submitting a request for an appeal to HHSC:

  • Form 3624, Termination, Reduction or Denial of CLASS
  • Written documentation established by the CMA in the event of a verbal request for appeal by individual/LAR (only if individual/LAR did not exercise their appeal rights using Form 3624)
  • Form 4800-D, Fair Hearing Request Summary
  • Form 4800-DA, 4800-D Addendum(only if there are more than three other hearing participants who require notification of a hearing)

3100, DSA Responsibilities

Revision 17-1; Effective November 1, 2017

All individuals who receive Community Living Assistance and Support Services (CLASS) program services and Community First Choice (CFC) Personal Assistance Services/Habilitation (PAS/HAB) must choose a direct services agency (DSA) with a valid provider agreement that operates in the catchment area in which the individual lives. Individuals who receive services through the CLASS program may request to transfer to another DSA at any time.

A DSA provides CLASS program services, CFCPAS/HAB services, and CFC emergency response services (ERS) to the individual as outlined in their Individual Plan of Care (IPC), the Individual Program Plan (IPP) for that service, and Individual Program Plan Addendum (IPP-A). An individual may elect to have some or all CLASS program and CFC services delivered by the DSA. Select services may be chosen for self-direction by the individual or legally authorized representative (LAR) using the Consumer Directed Services (CDS) option. For a complete list of CLASS and CFC services available using the CDS option, refer to Section 4000, Consumer Directed Services (CDS).

As outlined in this section, the individual's selected DSA is required to perform the following tasks on behalf of an individual in CLASS on an ongoing basis:

  • provide required documentation to HHSC as is necessary to assess and renew the level of care for the individual;
  • participate in developing a PAS/Habilitation Plan - CLASS/DBMD/CFC for individuals receiving CFC PAS/HAB services through the DSA to outline the individual's CFC PAS/HAB needs and complete documentation of that plan;
  • participate in developing an IPC that addresses all of the individual's needs that will be met through the provision of CLASS or CFC services;
  • participate in developing the IPP-A using person-centered planning processes for each individual;
  • provide all CLASS and CFC provider-managed services according to the IPP-A and the IPP;
  • monitor the DSA's service provision processes to ensure all services are delivered by qualified service providers in accordance with the IPP-A and IPP; and
  • coordinate with the CMA and other service providers as necessary to ensure IPP-A and IPC revisions are initiated as necessary in response to changes in the individual's needs.

CLASS program and CFC services, as a whole, enhance an individual's integration in the community and prevent admission to an institution while maintaining and improving independent functioning.

3110 Base of Operation

Revision 17-1; Effective November 1, 2017

CLASS program and CFC providers must have a base of operation that includes a physical location and normal operating hours in each geographic catchment area for which they have a contract to provide CLASS program and CFC services.

  1. A base of operation is a place in which business, clerical or professional activities are conducted. Each base of operation must:
    • maintain individual records for the CLASS program contract in the catchment area;
    • maintain personnel records for personnel who provide CLASS program and CFC services to individuals served in the catchment area;
    • be staffed by qualified employees who have completed CLASS program training and can readily become familiar with the individuals being served in the catchment area; and
    • maintain adequate staff to provide services and to supervise the provision of services within the catchment area.
  2. Providers must identify the base of operation's normal operating hours. If the base of operations is closed during its normal operating hours or between the hours of 8:00 a.m. and 5:00 p.m. Monday through Friday, the provider must:
    • post a notice in a visible location outside the base of operations to provide information regarding how to contact the person in charge; and
    • leave a message on an answering machine or similar electronic mechanism to provide information regarding how to contact the person in charge.

3120 DSA Staff Training Requirement

Revision 17-1; Effective November 1, 2017

3121 Initial Training for Direct Contact Staff

Revision 17-1; Effective November 1, 2017

Direct contact for the purposes of this manual means face-to-face contact with a CLASS individual a minimum of one time per calendar year. A DSA program director(s) and any DSA staff person who has direct contact with an individual receiving services through the CLASS program must complete one of the following within 60 calendar days of the employee beginning to work with the CLASS program:

  • In-person CLASS Provider Training provided by HHSC.
  • Training developed by the DSA that includes, at a minimum:
    • CLASS program overview;
    • person-centered planning;
    • philosophy and values of community integration;
    • overview of related conditions and CLASS program eligibility criteria;
    • service planning team (SPT) process;
    • utilization review process;
    • consumer directed services; and
    • individuals' rights and responsibilities including:
      • fair hearing process;
      • DSA's complaints process;
      • mandatory participation requirements; and
      • abuse, neglect and exploitation characteristics and reporting information.

The DSA could choose to conduct training at its location to meet the above requirements within 60 days of hiring the service provider. DSA staff that develop the curriculum used for initial training must have attended and successfully completed the CLASS Provider Training. The DSA must have a record to verify that the trainer has attended the CLASS Provider Training. The DSA may choose to send new employees to CLASS Provider Training at the next opportunity offered by HHSC to further reinforce training provided by the DSA.

Documentation of completion of required training must include, at a minimum:

  • CLASS Provider Training completion certificate with the name of the employee, signed by HHSC; or
  • written documentation of completion of the DSA's training that includes:
    • training topics covered;
    • method of training (i.e., reading, video, discussion, etc.);
    • name(s) and qualifications of instructor(s);
    • name of the trainee;
    • date the training was completed;
    • signature and date of the instructor(s); and
    • signature and date of the trainee verifying completion.

If a DSA develops curriculum to meet CLASS training requirements, the curriculum and training materials used must be maintained by the DSA and available to HHSC employees during a contract monitoring review. DSA staff that develop the curriculum used for initial training must have attended and successfully completed the CLASS Provider Training. Verification of the DSA training instructor's completion of CLASS Provider Training must be maintained and available to HHSC employees during a contract monitoring review.

3121.1 Initial Training for CFC PAS/HAB or CLASS Transportation-Habilitation and Respite Service Providers

Revision 17-1; Effective November 1, 2017

The DSA must ensure CFC PAS/HAB or CLASS habilitation and respite service providers:

  • receive in-person training in the habilitation activities necessary to meet the needs and characteristics of the individual to whom the service provider is assigned.
    • Training must occur in the individual's home with full participation from the individual, if possible; and
    • Form 3599, Habilitation Service Provider Orientation/Supervisory Visits, is used to document this orientation as stated in the directions for the form; and
  • complete two hours of habilitation training, developed by the DSA, before providing services to an individual in the CLASS program that includes at a minimum:
    • CLASS program overview;
    • overview of related conditions to include:
      • the definition of a related condition; and
      • examples of a related condition.
  • Receive an explanation of commonly performed tasks regarding CFC PAS/HAB.
  • Understand an individual's rights and responsibilities including:
    • DSA's complaints process;
    • mandatory participation requirements; and
    • abuse, neglect and exploitation characteristics and reporting information.
  • Providers of CLASS transportation-habilitation, prevocational and respite services must successfully complete hands-on training in cardiopulmonary resuscitation (CPR) and choking prevention before delivering services, and maintain training status as current while providing CLASS transportation-habilitation services. The training must include an in-person evaluation by a qualified instructor verifying the service provider's ability to perform these actions.
  • If requested by the individual or LAR, providers of CFC PAS/HAB must complete hands-on training in cardiopulmonary resuscitation (CPR) and choking prevention that includes an in-person evaluation by a qualified instructor verifying the service provider's ability to perform these actions. Maintaining training status of CPR training and choking prevention as current is determined by the individual or LAR.

The information specific to related conditions above is contained in the list of ICD-10 approved diagnostic codes for persons with related conditions is located on the HHSC website at: /sites/default/files/documents/doing-business-with-hhs/providers/health/icd10-codes.pdf.

Annual evaluations by the supervisor that take place with the individual/LAR ensures that the needs of the individual are being met. Form 3599 is used to document this evaluation, as stated in the instructions for the form. Documentation of transportation-habilitation, prevocational, and respite service provider training outlined above or any training of CFC PAS/HAB provider requested by the individual or LAR must include a signed certificate of completion stating:

  • training topics covered;
  • method of training (i.e., reading, video, discussion, etc.);
  • name(s) and qualifications of instructor(s);
  • name of the trainee;
  • date the training was completed;
  • signature and date of the instructor(s); and
  • signature and date of the trainee verifying completion.

3122 Initial and Annual Training for All DSA Staff

Revision 17-1; Effective November 1, 2017

Within 60 calendar days of the employee beginning to work with the CLASS program and every 12 months, all DSA staff must receive training on:

  • Abuse, Neglect and Exploitation (ANE) Prohibited Against Individuals
    • review of the statute on abuse, neglect and exploitation at Human Resources Code, Chapter 48, §48.002 (2, 3 and 4);
    • signs and symptoms of ANE;
    • reporting requirements of ANE; and
    • how to report abuse, neglect and exploitation to DFPS at www.dfps.state.tx.us/Contact_Us/report_abuse.asp.
  • Rights and Responsibilities of Individuals
    • information about the rights of the individual who receives CLASS/CFC services as outlined in the Consumer Rights and Services booklet; and
    • review of CLASS/CFC rules in Chapter 45, Subchapter C, §45.301 and §45.302 concerning the Rights and Responsibilities of an Individual.

DSA staff that develop the curriculum used for initial and annual training must have attended and successfully completed the CLASS Provider Training. Verification of a DSA training instructor's completion of CLASS Provider Training must be maintained and available to HHSC employees during a contract monitoring review. If a DSA develops curriculum to meet CLASS training requirements, the curriculum and training materials used must be maintained by the DSA and available to HHSC employees during a contract monitoring review.

Any DSA staff person who is responsible for developing the IPP-A, a service IPP, or the, PAS/Habilitation Plan - CLASS/DBMD/CFC must complete person-centered service planning training approved by HHSC depending upon the staff date of hire. If the staff person was hired on or before June 1, 2015, the staff must complete the training by June 1, 2017. If the staff person was hired after June 1, 2015, the staff person must complete the training within two years after the hire date.

3123 Types of CFC PAS/HAB or CLASS Transportation-Habilitation Service Providers

Revision 17-1; Effective November 1, 2017

The two types of CFC PAS/HAB or CLASS transportation-habilitation service providers are:

  • regular CFC PAS/HAB or CLASS transportation-habilitation service providers who perform all of the CFC PAS/HAB services available within their scope of competency; and
  • special CFC PAS/HAB or CLASS transportation-habilitation services providers who may be used to initiate services or prevent a break in service.

3124 Qualifications of CFC PAS/HAB or CLASS Transportation-Habilitation Service Providers

Revision 17-1; Effective November 1, 2017

CFC PAS/HAB or CLASS transportation-habilitation services are performed by service providers who:

  • are employed by the DSA;
  • are not spouses of individuals and, if the individual is under 18, are not the parent;
  • have a current, valid Texas driver's license; and
  • maintain vehicle liability insurance in accordance with state law.

3125 Required Training for CFC PAS/HAB or CLASS Transportation-Habilitation Service Providers

Revision 17-1; Effective November 1, 2017

Before services begin, the CFC PAS/HAB or CLASS transportation-habilitation service provider must meet the supervisor or other staff member qualified to train the habilitation service provider in the specific needs of the individual at the individual's home. The CFC PAS/HAB or CLASS transportation-habilitation service provider receives a general orientation with the full participation of the individual, if possible, in the CFC PAS/HAB or CLASS transportation-habilitation activities necessary to meet the needs and characteristics of the individual to whom the service provider is assigned. Orientation of the service provider to the specific needs of the individual must be documented on Form 3599, Habilitation Service Provider Orientation/Supervisory Visits.

3125.1 Required Training for Certain Special CFC PAS/HAB or Special Transportation-Habilitation Service Providers

Revision 17-1; Effective November 1, 2017

Special transportation-habilitation service providers or special CFC PAS/HAB providers who have six continuous months of experience in delivering CFC PAS/HAB or CLASS transportation-habilitation services in any Medicaid program or a program that primarily serves individuals with intellectual disabilities can receive the orientation from the supervisor or other appropriate DSA staff by phone rather than in person.

The individual receiving CFC PAS/HAB services should participate in providing special CFC PAS/HAB providers any training on the activities necessary to meet the needs and characteristics of the individual and the specific needs of the individual at the individual's home. Orientation of the service provider to the specific needs of the individual must be documented on Form 3599, Habilitation Service Provider Orientation/Supervisory Visits.

After the first orientation to the special CFC PAS/HAB or special CLASS transportation-habilitation activities necessary to meet the needs and characteristics of an individual, the special CFC PAS/HAB or special CLASS transportation-habilitation service provider does not need to be reoriented if the individual's condition, tasks and hours remain unchanged. There are no limits on the length of time a special CFC PAS/HAB or special CLASS transportation-habilitation service provider may be used. The special CFC PAS/HAB or special CLASS transportation-habilitation service provider may serve the individual without retraining, as long as the individual's condition, tasks and hours remain unchanged. In addition, there are no restrictions with respect to the amount of time between the service provider's assignments.

3126 Documentation of Required Experience for Special Service Provider Exception

Revision 17-1; Effective November 1, 2017

Records provided by the employee, or records provided by a former or current employer that document the time the employee delivered direct care services, may be used to establish that a special CFC/PAS/HAB or special habilitation service provider meets requirements.

3200, Eligibility

Revision 17-1; Effective November 1, 2017

The DSA is responsible for verifying the individual's eligibility for the CLASS program by ensuring the following criteria are met:

  • the individual is determined by HHSC to meet the diagnostic and functional eligibility criteria for the CLASS program;
  • the individual has been diagnosed prior to age 22 with a related condition. as described in the Texas Approved Diagnostic Codes for Persons with Related Conditions;
  • the individual has a qualifying adaptive behavior level (ABL) of II, III, or IV (i.e., moderate to extreme deficits in adaptive behavior) obtained by administering a standardized assessment of adaptive behavior;
  • the individual demonstrates a need for  CFC PAS/HAB;
  • the individual requires and receives at least one CLASS Program service per month, and one CLASS service per year (monthly monitoring of services by a case manager meets this requirement);
  • the individual has an IPC cost for CLASS program services at or below $114,736.07;
  • the individual is not enrolled in another Medicaid waiver program; and
  • the individual resides in his own home or family home. Note: An individual is not considered to reside in his own home or family home if he is admitted to one of the facilities outlined in Section 2430, Suspension, and Section 3430, Suspension, for more than 180 consecutive calendar days.

Individuals who receive CLASS program and CFC services must maintain continuous eligibility as outlined above. The DSA must assess the individual at the time of enrollment, at least annually, and as necessary when an individual's situation changes that may result in the individual no longer meeting all CLASS eligibility criteria.

The DSA must verify Medicaid eligibility each month by monitoring the Medicaid Eligibility Service Authorization Verification (MESAV) system. The DSA must verify the individual is eligible in the month that is being checked. Documentation of this monthly verification of eligibility for Medicaid must be maintained by the DSA and available for review by HHSC staff. If an individual is found to be ineligible for Medicaid, the DSA must notify the case manager no later than the next business day. The DSA must maintain verifiable evidence of notifying the case manager.

CLASS program and CFC services may be terminated if the individual does not meet all eligibility criteria as outlined in Title 40 of the Texas Administrative Code (TAC) §45.406. For more information regarding termination of services, see Section 3400, Denial, Reduction, Suspension and Termination.

See Appendix V, ID/RC Processing, for additional information and detailed instructions for DSAs.

3300, Service Planning

Revision 17-1; Effective November 1, 2017

A DSA must ensure a representative from its agency participates as a member of an individual's SPT. A DSA representative must be a:

  • program director or meet program director qualifications;
  • registered nurse (RN); or
  • licensed vocational nurse (LVN).

Meetings of the SPT to develop the IPP-A, the IPP, enrollment IPC and the renewal IPC should be held in the individual's own home or family home whenever possible. If it is not possible, the SPT must document why the meeting could not be held in the individual's home and the meeting must be at a time and location that is mutually agreed upon by all mandatory members.

The case manager must use Form 3629, Individual Program Plan Addendum to document use of person-centered planning processes.

The case manager, using the discovery process as the basis for collecting information, develops the person-centered plan with the individual, LAR, the CMA, DSA representative and others, as requested by the individual or LAR.
Examples of the discovery process include, but are not limited to:

  • conversations with the individual, LAR and those who know the individual best, such as a provider staff, caregiver, family member and friend;
  • a method called Planning Alternative Tomorrows with Hope (PATH);
  • methods taught by The Learning Community for Person Centered Practices (TLCPCP);occur with the support of a group of people chosen by the individual (and the LAR on the individual's behalf).

The person-centered planning process

  • accommodates the individual's style of interaction, communication and preferences regarding time and setting;
  • identifies the individual's strengths, preferences, support needs and desired outcomes;
  • identifies what is important to the individual;
  • identifies and documents the individual's current and preferred living arrangement;
  • determines the Habilitation (HAB), Personal Assistance Services (PAS), Emergency Response Services (ERS) and Support Management needs of an individual;
  • assesses the individual's needs, functional impairments, ability to perform activities of daily living (ADLs), instrumental activities of daily living (IADLs) and health-related tasks;
  • identifies natural supports available to the individual and needed service system supports;
  • documents the individual's preferences for when to receive CFC services;
  • documents the risks to the individual's health and safety, as well as a plan to mitigate those risks;
  • identifies any special needs, requests or considerations staff should know when supporting this individual; and
  • documents the individual's unmet needs.

Additional guidance and information about person-centered planning can be found at The Learning Community.

The SPT should include, at a minimum, the individual/applicant or LAR, the case manager and a DSA representative. The individual or LAR may request the SPT include professionals who are qualified by certification or licensure, or training and experience in the needs of people with related conditions, or directly involved in the delivery of services and supports to the individual. If licensed or certified professionals attend the SPT meeting, this may be billed as a professional service only when the individual has an identified need for the service, and for actual time spent in the capacity of the respective discipline. The SPT may include any other people requested by the individual or LAR. The SPT will make every effort to accommodate these requests by the individual or LAR.

SPT activities to revise a current IPC may occur via conference call in lieu of a face-to-face meeting. If the individual/LAR requests an in person meeting, SPT members must make every effort to accommodate the request. Participation in an SPT via conference call is not reimbursable to the DSA using CFC PAS/HAB or CLASS transportation-habilitation.

An IPC must be signed in person by the SPT at enrollment and renewal SPT meetings. Revisions of the current service plan may be signed by facsimile.

After all requirements for eligibility are met, and at least annually thereafter, the case manager, the applicant/individual/LAR, DSA representative(s) and other persons as requested by the applicant/individual/LAR must meet to develop Form 3629, Individual Program Plan Addendum and a proposed Form 3621, CLASS/CFC – Individual Plan of Care.

The proposed IPC must specify:

  • the type of CLASS program and CFC services to be provided to the individual;
  • the number of units of each CFC or CLASS program service;
  • the estimated annual cost of all CFC services, other than CFC support management, or CLASS program services; and
  • other services or supports to be provided to the individual through sources other than the CFC or CLASS program.
  • the SPT will participate with the CMA to develop Form 3629.

The SPT will develop Form 8606, Individual Program Plan (IPP).

An IPP is needed for each CLASS program and CFC service listed on the proposed IPC. Each IPP describes:

  • the CLASS program and CFC service to be provided;
  • the frequency of service provision;
  • the duration of services;
  • observable and measurable goals and objectives;
  • the title of person responsible for implementing and monitoring goals and objectives;
  • justification for services based on needs identified by the SPT; and
  • support services provided through non-CFC or non-CLASS resources.

If the individual requests a therapeutic service (e.g., occupational therapy, physical therapy, speech and language pathology, behavioral support, audiology, dietary service, auditory enhancement training or any specialized therapy), the case manager must initiate Form 8606-A, Therapy Justifications – Attachment to IPP, based on the deliberations of the SPT. The case manager must coordinate the completion of Attachment A with the appropriate professional. Since this professional is employed by or contracts with the DSA, assistance from the DSA is vital to ensure the case manager performs this function. The signature date of the professional on Attachment A may precede the date of the IPC that identifies the individual's need for the service or continuation of the need for the service by no more than 120 days.

Each CLASS program and CFC service must be provided to an individual in accordance with the IPP-A, the individual's IPC and the individual's IPP for that service. A DSA must inform the individual's case manager throughout the IPC year of changes needed to the individual's IPP-A, IPC or IPPs.

On an ongoing basis, the DSA's responsibilities include:

  • participating in the SPT;
  • developing the PAS/Habilitation Plan - CLASS/DBMD/CFC  plan (only applicable to service(s) delivered through the provider-managed service delivery option);
  • developing service backup plans for individuals receiving nursing and/or CFC PAS/HAB  services when the SPT has determined the service is critical to an individual's health and safety (only applicable to nursing and/or CFC PAS/HAB service(s) delivered through the provider-managed service delivery option);
  • discussing with the individual and the service providers or natural supports identified in the service backup plan to determine whether or not the plan was effective, if the service backup plan is implemented;
  • documenting whether or not the plan was effective,
  • revising the plan with input from the SPT, if the plan was determined to be ineffective;
  • completing Form 8578, Intellectual Disability/Related Condition (ID/RC) Assessment, submitting to HHSC and providing additional information as requested by HHSC for the purposes of authorizing the individual's level of care;
  • delivering an array of CLASS program and CFC services in accordance with the IPP-A, IPC, and the IPP and in coordination with non-CLASS services;
  • providing services to the individual as defined in the IPP-A and the IPP;
  • implementing the individual's observable and measurable goals and objectives;
  • informing the individual of rights and responsibilities, including complaint procedures;
  • reporting the individual's changing needs and goals to the case manager;
  • working with community resources as necessary to ensure the provision of CLASS program and CFC services achieves the goal to provide flexible resources that increase personal independence and integration into the community;
  • coordinating individual providers of CLASS program and CFC services; and
  • documenting the provision of services and providing, based on the schedule in Appendix X of the CLASS Provider Manual, a periodic summary of IPC service accomplishments to the case manager.

3310 Enrollment

Revision 17-1; Effective November 1, 2017

At the time an applicant receives a written offer of a CLASS program vacancy from HHSC, the applicant must select a DSA within 30 calendar days after the date of the written offer from HHSC. HHSC notifies the selected DSA the applicant has chosen the agency to provide direct services according to the HHSC Selection Determination document.

Within 14 calendar days after receiving Form 3657, Pre-Enrollment Assessment, from the CMA, as evidenced by the fax transmittal date on the documents received from the CMA a DSA staff person must complete an initial face-to-face, in-home visit with the individual/LAR to inform the individual and LAR or person actively involved with the individual, orally and in writing, of the process by which they may file a complaint regarding CLASS Program services or CFC services provided by the DSA.

A DSA representative must also provide the following information regarding required use of the Electronic Visit Verification (EVV).

  • EVV will not change the services the individual receives.
  • The CFC PAS/HAB services provider will need the individual's permission to use the telephone to call a toll-free number at the start and at the end of work.
  • EVV helps HHSC make sure the individual is receiving authorized services.
  • EVV is mandatory for all DSAs and individuals receiving services from a CFC PAS/HAB services provider, unless the individual receives services through the Consumer Directed Services (CDS) option.
  • Failure to cooperate will result in the suspension or termination of services.
  • If the individual does not have a telephone or does not want the CFC PAS/HAB services provider to use his telephone, a fixed verification device can be placed in the home, which is used only to verify the CFC PAS/HAB services provider's start and end of work.

If the individual has additional questions, the DSA representative must provide any requested additional information on how EVV works.
Within 14 calendar days after receiving Form 3657 from the CMA, as evidenced by the fax transmittal date on the documents received from the CMA, the DSA must assign a registered nurse or an appropriate licensed professional to perform and complete the following functions:

  • a nursing assessment of the individual using the CLASS/DBMD Nursing Assessment form;
  • an adaptive behavior assessments of the individual, as described in, Intellectual Disability/Related Condition (ID/RC) Assessment instructions;
  • the Related Conditions Eligibility Screening Instrument; and
  • the ID/RC Assessment in accordance with form instructions.

To determine an individual's adaptive behavior level as part of establishing an individual's enrollment level of care (LOC), the DSA must complete one of the following ABL assessments according to the publisher's instructions:

  • Inventory for Client and Agency Planning (ICAP);
  • Vineland Adaptive Behavior Scales;
  • Scales of Independent Behavior – Revised (SIB-R); or
  • American Association of Intellectual and Developmental Disabilities (AAIDD) Adaptive Behavior Scales (ABS).

The DSA must ensure:

  • the applicant's physician attests to the applicant's diagnosis on the enrollment ID/RC Assessment;
  • the completed ID/RC Assessment is submitted to HHSC for approval within 30 days of notification of completion of the Pre-Enrollment Assessment conducted by the CMA;
  • the HHSC-approved ID/RC and the completed CLASS/DBMD Nursing Assessment is transmitted to the applicant's CMA within one business day after receiving notification of approval of the ID/RC from HHSC; and
  • a DSA representative is available to participate in the applicant's enrollment SPT meeting as convened by the case manager.

Form Resources

The following forms may need to be completed as part of the enrollment process:

  • Form 2067, Case Information
  • Form 3596, PAS/Habilitation Plan - CLASS/DBMD/CFC
  • Form 3599, Habilitation Service Provider Orientation/Supervisory Visits
  • Form 3621, CLASS/CFC – Individual Plan of Care
  • Form 3625, CLASS/CFC – Documentation of Services Delivered
  • Form 3627, Specialized Nursing Certification
  • Form 3628, Provider Agency Model Service Backup Plan
  • Form 3629, Individual Program Plan Addendum
  • Form 6515, CLASS/DBMD Nursing Assessment
  • Form 8507, Understanding Program Eligibility - CLASS/DBMD
  • Form 8662, Related Conditions Eligibility Screening Instrument
  • Form 8578, Intellectual Disability/Related Condition Assessment
  • Form 8606, Individual Program Plan (IPP)

Submission Standard — ID/RC

The following submission standards apply when submitting ID/RC paperwork to HHSC:

  • Form 8578, Intellectual Disability/Related Condition Assessment
  • Form 8662, Related Conditions Eligibility Screening Instrument
  • assessment scoring summary

Submission Standard — Pre-enrollment

The following submission standards apply when submitting paperwork containing funding proposals for pre-enrolment efforts to HHSC:

  • Form 3625, CLASS/CFC – Documentation of Services Delivered
  • Form 8578, Intellectual Disability/Related Condition Assessment

3320 DSA Renewal of Level of Care

Revision 19-4; Effective November 8, 2019

Continuing eligibility must be determined at least annually. As with the initial assessment, the DSA RN is required to complete an annual nursing assessment of the individual using the Form 6515, CLASS/DBMD Nursing Assessment form, Form 8578, Intellectual Disability/Related Condition (ID/RC) Assessment, Form 8662, Related Conditions Eligibility Screening Instrument (RCESI) (these documents must be completed every year), and an adaptive behavior level (ABL) assessment if the current one is greater than five years old, or is no longer valid.

Form 8578, Form 8662 and results of the current ABL assessment must be sent to HHSC at least 60 calendar days, but no more than 120 calendar days, before the expiration of an individual's IPC to establish that an individual continues to meet diagnostic/functional eligibility criteria. Once HHSC informs the DSA of the approval of diagnostic/functional eligibility, the DSA must submit a copy of the approved ID/RC and the completed CLASS/DBMD Nursing Assessment to the CMA by the next business day.

If an individual's ABL assessment is more than five years old or the individual's needs significantly change, the DSA must complete one of the following ABL assessments according to the publisher's instructions:

  • Inventory for Client and Agency Planning (ICAP);
  • Vineland Adaptive Behavior Scales;
  • Scales of Independent Behavior – Revised (SIB-R); or
  • American Association of Intellectual and Developmental Disabilities (AAIDD) Adaptive Behavior Scales (ABS).

A DSA representative, as defined in Section 3300, Service Planning, must participate as a member of the SPT to develop:

  • a renewal IPC — the CLASS program services on the proposed renewal IPC must meet the following standards, which:
    • are necessary to protect the individual's health and welfare in the community;
    • address the individual's related condition;
    • are not available to the individual through any other source including the Medicaid state plan, other governmental programs, private insurance or the individual's natural supports;
    • are the most appropriate type and amount of CLASS program and CFC services to meet the individual's needs; and
    • are cost effective.
  • a renewal IPP for each service proposed on the renewal IPC;
  • Form 3596, PAS/Habilitation Plan - CLASS/DBMD/CFC; and
  • a service backup plan for the following services, if the SPT determines the service is critical to the individual's health and safety and if the service is delivered by the DSA:
    • CFC PAS/HAB; and
    • nursing services.

CLASS program and CFC services as a whole enhance an individual's integration in the community and prevent admission to an institution while maintaining and improving independent functioning.

The DSA is responsible for assisting and providing documentation, as requested by the CMA.

A DSA is responsible for verifying in MESAV that each individual's enrollment, renewal, or revisions IPCs have been authorized by HHSC as documented on the IPC signed by the SPT.

Form Resources

The following forms may need to be completed as part of the renewal process:

  • Form 1740, Service Backup Plan
  • Form 2067, Case Information
  • Form 3596, PAS/Habilitation Plan - CLASS/DBMD/CFC
  • Form 3598, Individual Transportation Plan
  • Form 3621, CLASS/CFC – Individual Plan of Care
  • Form 3625, CLASS/CFC – Documentation of Services Delivered
  • Form 3628, Provider Agency Model Service Backup Plan
  • Form 3629, Individual Program Plan Addendum
  • Form 6515, CLASS/DBMD Nursing Assessment
  • Form 8578, Intellectual Disability/Related Condition Assessment (Page 1 and Page 3)
  • Form 8598, Non-Waiver Services
  • Form 8606, Individual Program Plan (IPP)
  • Form 8662, Related Conditions Eligibility Screening Instrument

Submission Standard

The following submission standards apply when submitting ID/RC paperwork to HHSC:

  • Form 6515, CLASS/DBMD Nursing Assessment
  • Form 8578, Intellectual Disability/Related Condition Assessment
  • Form 8662, Related Conditions Eligibility Screening Instrument
  • ABL assessment scoring summary

3330 Revision

Revision 17-1; Effective November 1, 2017

When the DSA is notified of a needed revision to the IPC, the DSA representative must contact the CMA within one business day. The DSA is responsible for assisting and providing documentation, as requested by the CMA to ensure:

  • a proposed IPC revision includes an IPP for each service revised on the proposed IPC and a revised Form 3596, PAS/Habilitation Plan - CLASS/DBMD/CFC, if applicable;
  • Individual Program Plan Addendum is revised to ensure continued accuracy for the individual and to be consistent with the IPC and IPPs; and
  • the CLASS program and CFC services on the proposed IPC revision must meet the following standards:
    • are necessary to protect the individual's health and welfare in the community;
    • address the individual's related condition;
    • are not available to the individual through any other source including the Medicaid state plan, other governmental programs, private insurance or the individual's natural supports;
    • are the most appropriate type and amount of CLASS program and CFC services to meet the individual's needs; and
    • are cost effective.

Within five business days after receipt of the IPP-A, IPP and IPC from the CMA, as evidenced by the fax transmittal date on the documents received from the CMA, the DSA must sign and return the IPP-A, IPP and IPC to the CMA. If any revised services provided by the DSA affect the service backup plan, PAS/Habilitation Plan - CLASS/DBMD/CFC plan or the IPP-A, the DSA must revise the existing plan to reflect these changes to program services.

A DSA is responsible for verifying in MESAV that each individual's enrollment, renewal, or revisions IPCs have been authorized by HHSC as documented on the IPC signed by the SPT.

3331 Immediate Jeopardy of CLASS Individual

Revision 17-1; Effective November 1, 2017

Immediate jeopardy is interpreted as a crisis situation in which the health and safety of an individual is at risk.

During circumstances when the individual's health and safety is placed in immediate jeopardy the DSA must provide the following services:

  • licensed vocational nursing;
  • specialized licensed vocational nursing;
  • registered nursing;
  • specialized registered nursing;
  • CFC PAS/HAB
  • respite;
  • dental treatment; or
  • adaptive aid.

These services must be provided even if they are not included on the individual's IPC. The DSA must, within seven calendar days after providing the service, submit to the CMA:

  • a description of circumstances necessitating the provision of the new service or the increase in the amount of the existing service; and
  • documentation by a registered nurse of the nurse's determination the service was necessary to prevent the individual's health and safety from being placed in immediate jeopardy.

The CMA must use the date which the DSA RN documented determination the individual was subject to immediate jeopardy without the provision of additional habilitation, respite, nursing, dental services, or an adaptive aid that is not included on the individual's IPC as the IPC revision effective date.

Form Resources

The following forms may need to be completed as part of the revision process:

3340 Transfer

Revision 15-2; Effective November 20, 2015

If an individual plans to move to another CLASS provider, the case manager must provide the individual the most current Selection Determination document for the applicable catchment area. The requirements for the transferring DSA and receiving DSA are provided below.

3341 Transferring DSA

Revision 17-1; Effective November 1, 2017

The transferring DSA must provide the receiving DSA with the current balance of each service category based on most current CLASS/CFC IPC authorized and actual delivery up to the transfer effective date — Form 3621-T, CLASS/CFC – IPC Service Delivery Transfer Worksheet. The total number of service units provided before the effective date of the transfer is the sum of the number of service units:

  • provided and paid,
  • provided that have been billed but not yet paid, and
  • to be provided until the transfer effective date.

Copies of the identified records must be delivered by the transferring DSA to the receiving DSA within five calendar days of notification by the case manager of the individual's decision to transfer to a different DSA. The records that must be provided include:

  • current CLASS/CFC IPC;
  • current Form 3629, Individual Program Plan Addendum;
  • current Service Planning Team (SPT) notes from the current IPC period;
  • current Individual Program Plan (IPP);
  • current Form 8578, Intellectual Disability/Related Condition Assessment;
  • current Form 8662, Related Conditions Eligibility Screening Instrument;
  • current Form 3596, PAS/Habilitation Plan - CLASS/DBMD/CFC;
  • records of all adaptive aids purchased during the current IPC period;
  • records of all minor home modifications procured for the individual, regardless of date of purchase and cost of each;
  • all IPP Service Summaries performed by the DSA during the current IPC period;
  • current physician's orders;
  • copies of DSA records for 90 calendar days prior to DSA transfer, including:
    • CFC/PAS/HAB or CLASS habilitation;
    • medication administration record;
    • money management;
    • assessments and notes for any services listed on the IPC; and
    • all communications, including:
      • contact notes;
      • progress notes;
      • Form 2067, Case Information;
      • Form 3624, Termination, Reduction or Denial of CLASS;
      • incident reports; and
      • complaints;
  • school/day programming information including:
    • Admission, Review and Dismissal (ARD) notes; and
    • Individual Education Plan (IEP); and
  • current service delivery schedules for all services.

The transferring DSA is required to maintain documentation of the specific records that were delivered to the receiving DSA, as well as the date of the delivery.

3342 Receiving DSA

Revision 11-1; Effective June 13, 2011

The receiving DSA must initiate services on the transfer effective date, as identified on Form 3621-T, CLASS/CFC – IPC Service Delivery Transfer Worksheet. The total number of service units available to the receiving DSA is the number of service units to be provided from the transfer effective date until the end of the IPC effective period.

The receiving DSA must develop a Form 3628, Provider Agency Model Service Backup Plan, for those services requiring a backup plan as indicated on the IPC.

3350 IPP Service Summaries

Revision 17-1; Effective November 1, 2017

CLASS service provider(s) must evaluate the effectiveness of CLASS program and CFC services delivered by the DSA. The DSA is responsible for providing an IPP Service Summary to the CMA in accordance with the schedule in Appendix X, Service Summary/Service Review Due Dates Chart, from the effective date of the most recent enrollment or renewal CLASS/CFC IPC. The final review of the IPC year is combined with the meeting of the SPT to develop a renewal IPC and update the IPP-A. The case manager is responsible for documenting the service summary provided by the DSA since the preceding review. The evaluation must include an assessment of the individual's progress, evolving needs and plans to address those needs. The IPP Service Summary must document the service provider's review of the individual's progress toward achieving the goals and objectives, as described on the IPP for each CLASS program and CFC service listed on the individual's IPC. There is not a HHSC form for the IPP Service Summary; however, the DSA must provide this information in a written format.

A DSA is required to ensure that each CLASS program and CFC service is provided to an individual in accordance with Appendix C of the CLASS Waiver Application, available on the CLASS website at https://hhs.texas.gov/laws-regulations/policies-rules/waivers.

An IPP is developed to describe the goals and objectives to be met by the provision of each CLASS program and CFC service on an individual's IPC that are supported by justifications, are measurable, and have timelines. Additionally, a DSA must ensure CLASS program and CFC services are documented in the individual's record, including the progress or lack of progress in achieving goals or outcomes in observable, measurable terms that directly relate to the specific goal or objective addressed.

The DSA must provide the case manager with the IPP Service Summaries from each service listed below provided by the DSA documenting the individual's progress and needs. The service provider of each service listed below completes a service summary for each individual

Within five business days of the service provider completing the IPP service summary, the DSA is responsible for providing copies of the summaries to the case manager, as evidenced by the fax transmittal date on the documents provided to the CMA. The DSA must maintain documentation of transmission of all necessary documents. An IPP service summary for each service listed below must be prepared based on the schedule in Appendix X from the effective date of the most recent enrollment or renewal IPC. The DSA verbally updates the case manager during the renewal SPT meeting with any relevant information regarding services delivered in the last quarter of the IPC year.

The summaries must include quarterly reports from providers of the following services:

  • auditory enhancement training;
  • behavioral support;
  • dietary services;
  • occupational therapy;
  • physical therapy;
  • prevocational services;
  • specialized therapies;
  • speech and language pathology;
  • cognitive rehabilitation therapy;
  • employment assistance; and
  • supported employment services.

Each IPP Service Summary completed by the service provider must include all of the elements listed below:

  • current observable/measurable goals and objectives;
  • frequency and duration of sessions attended;
  • rationale for missed sessions;
  • progress or lack of progress;
  • actions taken, as applicable (e.g., in-servicing, counseling, etc.); and
  • revisions of goals and objectives, as applicable.

Form Resources

The following forms may need to be completed as part of the summary:

3400, Denial, Reduction, Suspension and Termination

Revision 17-1; Effective November 1, 2017

An individual who has been denied enrollment or terminated from the CLASS program and CFC services, or an individual whose CLASS program and CFC services are denied, reduced, suspended or terminated must be given notice of adverse actions taken by HHSC and is entitled to a fair hearing.

Program services may be terminated if the individual does not comply with the conditions as outlined in 40 TAC §45.406 or violates any of the conditions specified in 40 TAC §45.408. Program services may also be terminated if an individual does not comply with 40 TAC §45.407, or exhibits behavior that places the health and safety of the CMA's case manager or a DSA's service provider in immediate jeopardy as described in 40 TAC §45.409

3410 Denial

Revision 17-1; Effective November 1, 2017

Denial is an HHSC action that disallows:

  • an individual's request for enrollment in the CLASS program;
  • a service requested on the IPC that was not authorized on a prior IPC; or
  • a portion of the amount or level of the service requested on the IPC that was not authorized on a prior IPC.

3411 Denial of a Request for Enrollment into the CLASS Program

Revision 17-1; Effective November 1, 2017

HHSC denies an individual's request for enrollment into the CLASS program if:

  • the individual does not meet the eligibility criteria described in §45.201, Eligibility Criteria; or
  • the DSAs serving the catchment area in which the individual resides are not willing to provide CLASS program and CFC services to the individual because they have determined they cannot ensure the individual's health and safety.

If HHSC denies an individual's request for enrollment, HHSC sends written notice to the individual or LAR of the denial of the individual's request for enrollment into the CLASS program and includes in the notice the individual's right to request a fair hearing in accordance with §45.301, Individual's Right to a Fair Hearing. HHSC sends a copy of the written notice to the individual's DSA, CMA and, if selected, Financial Management Services Agency (FMSA).

3412 Denial of a CLASS Program or CFC Service

Revision 17-1; Effective November 1, 2017

CLASS program and CFC services as a whole enhance an individual's integration in the community and prevent admission to an institution while maintaining and improving independent functioning.

HHSC denies a CLASS program or CFC service on an individual's IPC if services:

  • are not necessary to protect the individual's health and welfare in the community;
  • do not address the individual's related condition;
  • are available to the individual through any other source including the Medicaid state plan, other governmental programs, private insurance or the individual's natural supports;
  • are not the most appropriate type and amount of CLASS program and CFC services to meet the individual's needs; or
  • are not cost effective.

If HHSC determines one or more of the CLASS program or CFC services specified in the IPC do not meet the requirements for an IPC, HHSC:

  • for an enrollment IPC, approves enrollment in CLASS program with the modified IPC;
  • denies the CLASS program or CFC service(s), as appropriate;
  • modifies and authorizes the IPC;
  • sends a copy of the modified IPC to the CMA; and
  • notifies the individual's CMA, in writing, of the action taken.

Form Resources

The following forms may need to be completed as part of a denial of services:

3420 Reduction

Revision 17-1; Effective November 1, 2017

Reduction is an HHSC action taken because of a review of an IPC that decreases the amount or level of CLASS program or CFC services not authorized by HHSC on a prior IPC.

HHSC will perform a utilization review on all IPCs that meet criteria outlined in Section 5000, Utilization Review (UR). All CLASS program or CFC services and units of service included on a proposed IPC must be justified by the SPT.

HHSC staff review the IPC to ensure the services on the IPC:

  • are necessary to protect the individual's health and welfare in the community;
  • supplement rather than replace the individual's natural supports and other non-CLASS program services and supports for which the individual may be eligible;
  • CLASS program and CFC services as a whole enhance an individual's integration in the community and prevent admission to an institution while maintaining and improving independent functioning;
  • are the most appropriate type and amount of CLASS program and CFC services to meet the individual's needs; and
  • are cost effective.

As necessary during the review of a proposed IPC, HHSC staff will ask case managers to provide additional justification if the initial information submitted with a proposed IPC is not sufficient to demonstrate the need for a proposed CLASS program and CFC service(s). If information submitted to HHSC by the case manager does not provide sufficient information to justify requested CLASS program and CFC services or amounts of CLASS program and CFC services, HHSC will reduce the number of units of CLASS program and CFC services, as necessary, and will send the CMA a copy of the modified IPC.

If an individual's services are reduced, CMA notifies the DSA in writing describing HHSC's reason for the reduction. The CMA also notifies the DSA if and when the individual chooses to appeal the decision. If the individual or LAR requests a fair hearing within 10 days from date of notification, as specified in the written notice, the DSA must provide the service to the individual in the amount authorized in the prior IPC while the appeal is pending.

Form Resources

The following forms may need to be completed as part of a reduction of services:

3430 Suspension

Revision 17-1; Effective November 1, 2017

Suspension is an HHSC action that results in temporary loss of the individual's authorized CLASS program or CFC services. An individual may remain on suspension from CLASS for up to 180 calendar days. HHSC may extend an individual's suspension for 30 calendar days upon the CMA's request.

Suspension is an HHSC action taken because of:

  • an individual's admission, for up to180 consecutive calendar days, to one of the following facilities:
    • an ICF/IID licensed or subject to being licensed in accordance with Texas Health and Safety Code, Chapter 252, or certified by HHSC, unless the individual is receiving out-of-home respite in the facility;
    • a nursing facility licensed or subject to being licensed in accordance with Texas Health and Safety Code, Chapter 242, unless the individual is receiving out-of-home respite in the facility;
    • an assisted living facility licensed or subject to being licensed in accordance with Texas Health and Safety Code, Chapter 247;
    • a residential child-care operation licensed or subject to being licensed by the Texas Department of Family and Protective Services (DFPS), unless it is a foster family home or a foster group home;
    • a facility licensed or subject to being licensed by the Texas Department of State Health Services (DSHS);
    • a facility operated by HHSC;
    • a residential facility operated by the Texas Youth Commission; or
    • a jail or prison;
  • an individual leaving the state for up to 180 consecutive calendar days, except for individuals receiving certain services available through the CDS option while the individual is temporarily staying at a location outside the state of Texas. For more information, see Information Letter No. 16-35, Receiving Services Outside the State of Texas in the CLASS and DBMD Programs.

Within two business days of learning of a situation that necessitates an individual's CLASS program and CFC services to be suspended, the DSA must send the CMA written notification using Form 2067, Case Information, including any supporting documentation.

Form Resources

The following forms may need to be completed as part of a suspension of services:

3440 Termination

Revision 11-7; Effective November 1, 2017

Termination is an HHSC action that results in the loss of the individual's eligibility for authorized services in the CLASS program and CFC services.

3441 Termination With Advanced Notice

Revision 11-7; Effective November 1, 2017

HHSC terminates an individual's CLASS program and CFC services if:

  • the individual does not meet program eligibility criteria;
  • the individual is admitted for more than 180 consecutive calendar days to one of the following facilities:
    • an ICF/IID licensed or subject to being licensed in accordance with Texas Health and Safety Code, Chapter 252, or certified by HHSC, unless the individual is receiving out-of-home respite in the facility;
    • a nursing facility licensed or subject to being licensed in accordance with Texas Health and Safety Code, Chapter 242, unless the individual is receiving out-of-home respite in the facility;
    • an assisted living facility licensed or subject to being licensed in accordance with Texas Health and Safety Code, Chapter 247;
      • a residential child-care operation licensed or subject to being licensed by the DFPS, unless it is a foster family home or a foster group home;
      • a facility licensed or subject to being licensed by the DSHS;
      • a facility operated by HHSC; or
      • a residential facility operated by the Texas Youth Commission, a jail or prison;
  • the individual leaves the state for more than 180 consecutive calendar days and HHSC has not extended the individual's suspension;
  • DSAs serving the catchment area in which the individual resides are not willing to provide CLASS program and CFC services to the individual on the basis of a reasonable expectation that the individual's medical and nursing needs cannot be met adequately in the individual's residence; or
  • the individual refuses to comply with one or more of the mandatory participation requirements as follows:
    • not completing and submitting an application for Medicaid financial eligibility to HHSC within 30 calendar days after the case manager's initial face-to-face, in-home visit (Note: If an individual or LAR does not submit a Medicaid application to HHSC within 30 calendar days of the case manager's initial face-to-face, in-home visit as required, but is making good faith efforts to complete the application, HHSC may extend this time frame in 30 calendar-day increments.);
    • not participating with the SPT to:
      • develop the IPP-A using the person-centered planning process;
      • develop an enrollment CFC/CLASS IPC; or
      • renew and revise the IPC and IPPs;
    • not reviewing, agreeing to, signing and dating an IPC and IPPs;
    • not using natural supports and other non-CLASS services and supports for which the individual may be eligible before using CLASS and CFC services;
    • not cooperating with the CMA and DSA in the delivery of CLASS and CFC services listed on the individual's IPC, including:
      • not cooperating with the CMA and DSA in scheduling meetings;
      • not attending scheduled meetings with the case manager or service provider;
      • not being available to receive the CLASS and CFC services;
      • not notifying the CMA or DSA in advance if the individual or LAR is unable to attend a scheduled meeting or is unavailable to receive services in the individual's own or family home;
      • not admitting CMA and DSA representatives to the individual's own home or family home for a scheduled meeting or to receive CLASS and CFC services;
    • not cooperating with the DSA's service providers to ensure progress toward achieving the goals and objectives described in the IPP for each CLASS service listed on the IPC;
    • not paying a required copayment in a timely manner as required by HHSC;
    • not completing the procedures for redetermining eligibility for Medicaid as described in the Medicaid for the Elderly and People with Disabilities Handbook;
    • engaging or permitting a person present in the individual's own or family home to engage in criminal behavior in the presence of the case manager or service provider;
    • acting or permitting a person present in the individual's own or family home to act in a manner that is threatening to the health and safety of the case manager or service provider;
    • exhibiting behavior or permitting a person present in the individual's residence to exhibit behavior that places the health and safety of the case manager or service provider in immediate jeopardy;
    • initiating or participating in fraudulent health care practices; or
    • engaging or permitting a person present in the individual's own home or family home to engage in behavior that endangers the individual's health or safety.

Within two business days after the DSA learns of one of the situations described above, the DSA must send the CMA a written notification per Form 2067, Case Information, including supporting documentation. The DSA is responsible for making reasonable attempts to accommodate a face-to-face meeting with the SPT as scheduled by the CMA.

If termination of services is requested based on a determination by the DSA on the basis of a reasonable expectation that the individual's medical and nursing needs cannot be met adequately in the individual's residence, the DSA must provide specific reason(s) to the CMA regarding why the DSA determined it cannot ensure the individual's health and safety.

Prior to termination of services, an individual may choose another DSA. The CMA must provide the most current Selection Determination document in catchment areas with multiple DSAs. If another DSA determines the individual's medical and nursing needs can be adequately met, the DSA must assist the CMA to develop a transfer IPC as described in Section 3340 of the CLASS Provider Manual.

HHSC notifies the individual's CMA, in writing, of whether it authorizes the proposed termination of CLASS program and CFC services. The DSA is notified by the CMA regarding the termination.

If CLASS program and CFC services are terminated due to an individual's IPC cost being over $114,736.07,  HHSC sends written notice to the individual or LAR of the proposal to terminate CLASS program and CFC services and includes in the notice the individual's right to request a fair hearing. HHSC sends a copy of the written notice to the individual's DSA, CMA and, if selected, FMSA.

HHSC notifies the individual's CMA, in writing, of whether it authorizes the proposed termination of CLASS program and CFC services. The DSA is notified by the CMA regarding the termination.

If the individual or LAR requests a fair hearing before the effective date of a proposed termination of CLASS program and CFC services, the DSA must provide services to the individual in the amounts authorized in the IPC while the appeal is pending.

3442 Termination Without Advanced Notice

Revision 17-1; Effective November 17, 2017

HHSC terminates an individual's CLASS program and CFC services without advanced notice if any of the following situations exist:

  • the CMA or DSA has factual information confirming the death of the individual;
  • the CMA or DSA receives a clearly written statement signed by the individual that the individual no longer wishes to continue to receive CLASS program and CFC services;
  • the individual's whereabouts are unknown and the post office returns mail directed to him or her by the CMA or DSA, indicating no forwarding address;
  • the CMA or DSA establishes the individual has been accepted for Medicaid services by another state; or
  • an individual or a person in the individual's residence exhibits behavior that places the health and safety of the CMA's case manager or a DSA's service provider in immediate jeopardy. For more information, see Section 3510, Immediate Jeopardy.

Within two business days after the DSA becomes aware of a situation such as described above, the DSA must send the CMA a written notification per Form 2067, Case Information, including supporting documentation.

HHSC notifies the individual's CMA, in writing, of whether it authorizes the termination of CLASS and CFC services. The DSA is notified by the CMA regarding the termination.

HHSC may terminate an individual's CLASS and CFC services if an individual or a person in the individual's residence exhibits behavior that places the health and safety of the case manager or a service provider in immediate jeopardy.

If a CMA or DSA becomes aware of an existing situation that places the health and safety of the individual's case manager or CLASS program or CFC service provider in immediate jeopardy, the CMA or DSA must:

  • immediately file a report with the appropriate law enforcement agency and, if appropriate, make an immediate referral to DFPS;
  • notify the CMA or DSA, as appropriate, and HHSC by telephone of the situation no later than the next business day; and
  • attempt to resolve the situation.

HHSC notifies the individual's CMA, in writing, of whether it authorizes the proposed termination of CLASS and CFC services. The DSA is notified by the CMA regarding the termination.

Form Resources

The following forms may need to be completed as part of termination of services:

3500, Service Initiation

Revision 17-1; Effective November 1, 2017

A DSA must ensure each CLASS and CFC service is provided to an individual in accordance with the individual's IPP-A, IPC and IPP for each service.

A DSA must have a written process that ensures staff members are or can readily become familiar with individuals to whom they are not ordinarily assigned but to whom they may be required to provide a CLASS and CFC service.

A DSA must inform the individual's case manager of changes needed to the individual's IPC or IPPs.

3510 Immediate Jeopardy of CLASS and CFC Providers

Revision 17-1; Effective November 1, 2017

HHSC may terminate an individual's CLASS program and CFC services if an individual or a person in the individual's residence exhibits behavior that places the health and safety of the CMA's case manager or a DSA's service provider in immediate jeopardy.

If a CMA or DSA becomes aware of an existing situation that places the health and safety of the individual's case manager or DSA service provider in immediate jeopardy, the CMA or DSA must:

  • immediately file a report with the appropriate law enforcement agency and, if appropriate, make an immediate referral to DFPS; and
  • notify HHSC, CMA and DSA by telephone of the situation no later than one business day after the CMA or DSA becomes aware of the situation.

The CMA and DSA must attempt to resolve the situation. If, after making attempts to resolve the situation, the CMA determines that the situation cannot be resolved, the CMA must, within two business days after the CMA becomes aware of the situation, send a written request to terminate CLASS program and CFC services to HHSC. The written request must be accompanied by:

  • a description of the situation that resulted in the request to terminate the individual's CLASS program and CFC services;
  • a detailed description of the attempts by the CMA to resolve the situation; and
  • if available, a copy of any report issued by a law enforcement agency or DFPS regarding the situation.

HHSC notifies the individual's CMA in writing of whether it authorizes the proposed termination of CLASS program and CFC services.

Upon receipt of a written notice from HHSC authorizing the termination of CLASS program and CFC services, the CMA must, no later than the date of the termination of services, send a written notice to the individual or LAR of such termination. The CMA must provide a hard copy of the termination notice to the individual's DSA and, if selected, FMSA and SFS provider. The CMA must include in the notice the individual's right to request a fair hearing.

The CMA and DSA must maintain documentation of completion of these requirements in the individual's record.

3520 Adaptive Aids Costing Less than $500

Revision 17-1; Effective November 1, 2017

Once the DSA determines the cost of the requested adaptive aid, the DSA must request in writing that the case manager initiate an IPC revision. The DSA must inform the individual's case manager of the cost of the requested adaptive aid.

HHSC authorizes the IPC submitted by the CMA if, after reviewing the documentation, it determines the requested adaptive aid meets the standards outlined in Appendix I, Adaptive Aids.

The DSA must ensure the individual receives the adaptive aid within 14 business days after the date HHSC authorizes the proposed IPC that includes the recommended adaptive aid; or the effective date of the individual's IPC as determined by the SPT (whichever is later). The DSA must complete Form 8605, Documentation of Completion of Purchase, that serves as the primary document for completion of purchases of authorized adaptive aids/medical supply items or minor home modifications made by the service provider for individuals.

For an adaptive aid that is a medical supply, a DSA must ensure the individual receives the medical supply as follows:

  • for a medical supply that is not immediately needed by the individual, within five business days after the date HHSC authorizes the proposed IPC that includes the recommended adaptive aid; or the effective date of the individual's IPC as determined by the SPT (whichever is later); or
  • for a medical supply that is immediately needed by the individual, within two business days after the date HHSC authorizes the IPC that includes the recommended adaptive aid.

If the DSA cannot provide the adaptive aid in the time frame described, the DSA must:

  • notify the individual and the individual's case manager, orally or in writing, before the 14-day time frame expires, that the adaptive aid will not be provided within the 14-day time frame; and
  • notify the individual and the individual's case manager of a new proposed date for provision of the adaptive aid.

If the DSA cannot provide an adaptive aid that is a medical supply and is not immediately necessary by the individual, the DSA must:

  • notify the individual and the individual's case manager, orally or in writing, before the five-day time frame expires, that the adaptive aid will not be provided within the five-day time frame;
  • provide the reason(s) why the medical supply will not be provided within the five-day time frame; and
  • notify the individual and the individual's case manager of a new proposed date for provision of the medical supply.

3530 Adaptive Aid Costing $500 or More

Revision 17-1; Effective November 1, 2017

Once the SPT has agreed the individual is in need of an adaptive aid with an anticipated cost that is more than $500, the DSA must request in writing that the case manager initiate an IPC revision including funds for obtaining an assessment of the individual by the appropriate licensed professional as described in Appendix I of CLASS Provider Manual. The assessment must include a description and a recommendation for an adaptive aid that meets the individual's need(s). This assessment must identify how this adaptive aid will meet the needs of the individual and must include consideration of other alternatives known to the appropriate licensed professional to meet the individual's need(s). Detailed descriptions, to the extent possible, must accompany the licensed professional's recommendation for adaptive aids when the cost is more than $500.

After HHSC authorizes the proposed IPC for payment of the adaptive aid assessment, the DSA must obtain the assessment from the appropriate licensed professional that describes the adaptive aid within 30 calendar days. The assessment by the licensed professional that describes the specific need(s) of the individual must include recommendations for the adaptive aid that, in the opinion of the licensed professional, will best meet the needs identified in the assessment.

Based on the recommendations contained in the assessment, the DSA will consult with the appropriate vendor  to determine the most cost-effective item(s) that meet the recommendations in the assessment. The description of the item(s) as contained in the assessment must be used to develop the specifications to obtain bids from all vendors. The DSA must obtain comparable bids for the requested adaptive aid from three vendors within 60 calendar days of obtaining the specifications.

A bid obtained must be based on the specifications and include:

  • the total cost of the requested adaptive aid, which may be from a catalog, website or brochure price list;
  • the amount of any additional expenses related to the delivery of the adaptive aid, including shipping and handling, taxes, installation and other labor charges;
  • the date of the bids;
  • the name, address and telephone number of the vendor, who may not be a relative of the individual;
  • a complete description of the adaptive aid and any associated items or modifications as identified in the completed Form 3660, Request for Adaptive Aids, Medical Supplies, Minor Home Modifications or Dental Services/Sedation, which may include pictures or other descriptive information from a catalog, website or brochure; and
  • the number of hours of the service or training to be provided in person and the hourly rate of the service for interpreter services and specialized training for augmentative communication programs.

The DSA must:

  • obtain the assessment from a licensed professional for the adaptive aid as described in Appendix I, Adaptive Aids;
  • ensure the assessment includes a complete description of the adaptive aid; and
  • provide a copy of the assessment and the specifications to the CMA.

For purchases of an adaptive aid or medical supply costing over $500, the CMA, DSA and individual/legally authorized representative must complete and sign Form 3849-A, Specifications for Adaptive Aids/Medical Supplies/Minor Home Modifications, to signify agreement with the specifications.

The DSA may obtain only one bid or two comparable bids for an adaptive aid if the DSA has written justification for obtaining less than three bids because the adaptive aid is available from a limited number of vendors.

A bid obtained must be based on the specifications and include:

  • the total cost of the requested adaptive aid, which may be from a catalog, website or brochure price list;
  • the amount of any additional expenses related to the delivery of the adaptive aid, including shipping and handling, taxes, installation and other labor charges;
  • the date of the bid;
  • the name, address and telephone number of the vendor, who may not be a relative of the individual;
  • a complete description of the adaptive aid and any associated items or modifications as identified in the completed Form 3660, which may include pictures or other descriptive information from a catalog, website or brochure; and
  • the number of hours of the service or training to be provided in person and the hourly rate of the service for interpreter services and specialized training for augmentative communication programs.

A DSA may obtain only one bid or two comparable bids for an adaptive aid if the DSA has written justification for obtaining less than three bids because the adaptive aid is available from a limited number of vendors.

If a DSA requests to purchase an adaptive aid that is not based on the lowest bid, the DSA must have written justification for payment of a higher bid. The following are examples of justifications that support payment of a higher bid:

  • the higher bid is based on the inclusion of a longer warranty for the adaptive aid; and
  • the higher bid is from a vendor that is more accessible to the individual than another vendor.

Requests for interpreter services or specialized training for augmentative communication devices must include:

  • the total number of hours of the service or training to be provided in-person; and
  • the hourly rate of the service.

If the requested adaptive aid is a vehicle modification, a DSA must obtain proof the individual or individual's family member owns the vehicle for which the vehicle modification is requested. Requests for vehicle modifications to accommodate modifications or additions to the primary transportation vehicle must include an assessment by the appropriate licensed professional as indicated in Appendix I. Additionally, if the vehicle is more than five years old or the mileage on the vehicle odometer exceeds 50,000 miles, the vehicle must pass an inspection performed by an automotive technician certified by The National Institute for Automotive Service Excellence (ASE).

A DSA may not disclose information regarding a submitted bid to any other vendor who has submitted a bid or to a vendor who may submit a bid.

The DSA must request in writing the case manager initiate an IPC revision. At this point, the DSA must inform the individual's case manager of the cost of the requested adaptive aid.

HHSC authorizes the IPC once submitted by the CMA if, after reviewing the documentation, it determines the requested adaptive aid meets the standards outlined in Appendix I, Adaptive Aids.

The DSA must ensure the individual receives the adaptive aid within 30 business days after the date HHSC authorizes the proposed IPC that includes the recommended adaptive aid; or the effective date of the individual's IPC as determined by the SPT (whichever is later). The DSA must complete Form 8605, Documentation of Completion of Purchase, that serves as the primary document for purchases of authorized adaptive aids/medical supply items or minor home modifications made by the service provider for individuals.

For an adaptive aid that is a medical supply, the DSA must ensure the individual receives the medical supply as follows:

  • for a medical supply that is not immediately needed by the individual, within five business days after the date HHSC authorizes the proposed IPC that includes the recommended adaptive aid; or the effective date of the individual's IPC as determined by the SPT (whichever is later); or
  • for a medical supply that is immediately needed by the individual, within two business days after the date HHSC authorizes the IPC that includes the recommended adaptive aid.

If the DSA cannot provide the adaptive aid in the time frame described, the DSA must:

  • notify the individual and the individual's case manager, orally or in writing, before the 30-day time frame expires, the adaptive aid will not be provided within the 30-day time frame; and
  • notify the individual and the individual's case manager of a new proposed date for provision of the adaptive aid.

For an adaptive aid that is a medical supply and not immediately needed by the individual, the DSA must:

  • notify the individual and the individual's case manager, orally or in writing, before the five-day time frame expires the adaptive aid will not be provided within the five-day time frame;
  • provide the reasons why the medical supply will not be provided within the five-day time frame; and
  • notify the individual and the individual's case manager of a new proposed date for provision of the medical supply.

3540 Minor Home Modification

Revision 17-1; Effective November 1, 2017

Once the SPT has agreed the applicant/individual might require a minor home modification, the DSA must request in writing that the case manager initiate an IPC revision that includes funds for obtaining an assessment of the individual by the appropriate licensed professional to determine the specific minor home modification necessary to meet the needs of the individual, as defined in the assessment.

Once HHSC notifies a DSA through the electronic billing system of a service authorization for an assessment by the appropriate licensed professional of the individual's need(s), the DSA must obtain the assessment within 30 calendar days after the date HHSC authorizes the IPC.

After HHSC authorizes the proposed IPC for payment for the assessment of the individual, the DSA must obtain the specifications from a person who has experience in home modifications within 30 calendar days.

The DSA must:

  • obtain an assessment of the individual from a licensed professional that describes the specific minor home modification, as described in Appendix II, Minor Home Modification Services. The assessment must include a complete description of the specific need(s) of the individual and recommendations for the minor home modification that will meet the needs identified in the assessment.
  • provide a copy of the assessment to the CMA;
  • obtain the specifications from a person who has experience in constructing home modifications, based on the assessment completed by the professional; and
  • ensure the specifications meet the following standards:
    • include a complete description of the minor home modification and any required installations identified in the specifications;
    • include a drawing or picture of both the existing room, structure or other area and the proposed modification made to scale;
    • be approved in writing by each member of the SPT by completing Form 3849-A, Specifications for Adaptive Aids/Medical Supplies/Minor Home Modifications; and
    • comply with the Texas Accessibility Standards promulgated by the Texas Department of Licensing and Regulation unless:
      • DSA determines it is not structurally feasible to do so and the DSA documents, in writing, the basis for its determination; or
      • the individual or legally authorized representative (LAR) requests, in writing, the specifications not be in compliance with the Texas Accessibility Standards;
  • be approved, in writing, by the individual or LAR and the DSA by completing Form 3849-A, as described in Appendix II; and
  • provide a copy of the specifications to the CMA.

The CMA, DSA and individual/LAR must complete and sign Form 3849-A to signify agreement with the specifications.

The DSA must obtain comparable bids for a minor home modification from three vendors if the modification costs more than $1,000, within 60 calendar days after obtaining the specifications.

A bid obtained must be based on the specifications and include:

  • an itemized list of materials and labor necessary to construct the modification;
  • the cost of each material and labor listed;
  • the date of the bid;
  • the name, address and telephone number of the vendor, who may not be a relative of the individual;
  • a detailed explanation of the vendor's warranty for the modification, if any; and
  • a statement that the minor home modification will be made in accordance with all applicable state and local building codes.

A DSA may obtain one bid or two comparable bids for a minor home modification if the DSA has written justification for obtaining less than three bids because the minor home modification is available from a limited number of vendors.

If a DSA requests to purchase a minor home modification that is not based on the lowest bid, the DSA must have written justification for payment of a higher bid. The following are examples of justifications that support payment of a higher bid:

  • the higher bid is based on the inclusion of a longer warranty for the minor home modification; and
  • the higher bid is from a vendor that is more accessible to the individual than another vendor.

The person who developed the specifications may also offer one of the bids. A DSA may not disclose information regarding a submitted bid to any other vendor who has submitted a bid or to a vendor who may submit a bid.

After the DSA has successfully obtained a sufficient number of bids, the DSA must:

  • select a vendor to complete construction of the minor home modification;
  • obtain written approval for construction of the modification from the owner of the property in question, unless such approval is granted in an applicable lease agreement;
  • ensure the selected vendor obtains any required building permits; and
  • advise the CMA regarding the cost of the minor home modification and the cost of the inspection of the modification, so that an IPC revision can be initiated.

Once HHSC notifies a DSA through the electronic billing system of a service authorization for a planned minor home modification and the cost of the inspection of the modification, the DSA must direct the vendor to begin construction of the modification within seven calendar days after the date HHSC authorizes the proposed IPC; or the effective date of the IPC as determined by the SPT (whichever is later).

A DSA must ensure a minor home modification is completed within 60 calendar days after the date HHSC authorizes the proposed IPC that includes the cost of the modification and inspection or the effective date of the IPC as determined by the SPT (whichever is later).

If the DSA determines the minor home modification will not be completed within the time frame required, the DSA must notify the individual or LAR in writing of a new proposed date of completion. The proposed date may not exceed 30 calendar days after the date outlined before.

The DSA must conduct an in-person inspection of the minor home modification within seven business days after it receives information the modification is completed. The inspection may be performed by the person who developed the specifications unless that person is affiliated with the vendor who completed the minor home modification. The inspection will determine if the:

  • minor home modification has been completed;
  • modification has been made in accordance with the specifications; and
  • quality of workmanship of the modification is adequate.

If the DSA determines the minor home modification meets the conditions of the inspection, the DSA must send a completed Form 8605, Documentation of Completion of Purchase, to the individual's CMA within seven business days after completion of the inspection.

If the DSA determines the minor home modification does not meet the conditions of the inspection, the DSA must ensure the vendor meets the conditions within 30 calendar days after the DSA's determination.

3600, CFC PAS/HAB or CLASS Transportation-Habilitation Services Documentation

Revision 17-1; Effective November 1, 2017

If the individual receives CFC PAS/HAB or CLASS transportation-habilitation services as part of their service plan, the DSA must document and maintain the following in the individual record (except for items that are not relevant):

  • the need for specific CFC PAS/HAB or CLASS transportation-habilitation tasks;
  • standing physician's orders for any delegated tasks;
  • any training and/or other support provided including support management to the individual to enable the individual to manage their own CFC PAS/HAB or CLASS transportation-habilitation services;
  • conflicts/problems between the individual and the CFC PAS/HAB or CLASS transportation-habilitation staff, and how these conflicts/problems were resolved; and
  • annual documentation of the satisfaction with CFC PAS/HAB or CLASS transportation-habilitation using Form 3599, Habilitation Service Provider Orientation/Supervisory Visits.

Tasks performed by CFC PAS/HAB or CLASS transportation-habilitation provider  must be provided with proper regard for the individual's health, safety, welfare and personal autonomy. CFC PAS/HAB must be performed in a manner that comports with the individual's personal, cultural or religious preferences.

The DSA must provide CFC PAS/HAB services that meet the individual's needs as specified in the IPC and IPP. The individual or LAR must be afforded an informed choice of settings, techniques and objectives. The individual or LAR may request CFC PAS/HAB services be modified to accommodate individual needs.

CFC PAS/HAB must be provided in community settings; that is, places where the individual lives or works and in settings similar to these. The training must teach skills the individual can practice and apply in daily life.

If any of the following services are provided, the DSA must evaluate and document the effectiveness at least once per quarter:

  • prevocational services;
  • employment assistance; or
  • supported employment services.

The evaluation must include an assessment of the individual's progress, evolving needs and plans to address identified needs.

The DSA must also inform the case manager of any significant changes in the service plan and provide the case manager with service summaries of the individual's progress and needs.

Form Resources

The following forms may need to be completed:

  • Form 2067, Case Information
  • Form 3596, PAS/Habilitation Plan - CLASS/DBMD/CFC
  • Form 3599, Habilitation Service Provider Orientation/Supervisory Visits
  • Form 3621, CLASS/CFC – Individual Plan of Care
  • Form 3625, Documentation of Services Delivered
  • Form 3629, Individual Program Plan Addendum
  • Form 8606, Individual Program Plan (IPP)

3700, Money Management/Trust Fund

Revision 17-1; Effective November 1, 2017

The SPT will address the individual's need for money management assistance. If an individual requires assistance with money management, this can be addressed during completion of Form 3596, PAS/Habilitation Plan - CLASS/DBMD/CFC.

Individuals receiving CLASS and CFC services will be encouraged to practice responsible personal money management. If the DSA maintains the individual's finances, it must do so in a way that protects the financial interests of the individual receiving CLASS and CFC services.

Individuals receiving CLASS and CFC services will be encouraged and allowed to manage their own finances, whenever possible.

Individuals who are capable of managing their own finances will:

  • receive training by the DSA as needed to enable them to do so; and
  • establish a secure place to store cash.

If the individual does not manage their own funds, the DSA must explain in writing why the individual is unable to perform the activity and what steps are being taken to increase the individual's independence. The provider must also maintain the funds in accordance with trust fund requirements as noted in 40 TAC §19.405, Additional Requirements for Trust Funds in Medicaid-certified Facilities.

3800, Changes in Individual Status

Revision 11-1; Effective June 13, 2011

The DSA must report changes in an individual's status within 24 hours of awareness of the change to the case manager on Form 2067, Case Information.

The following are examples of changes in the individual's condition or circumstances that require notification to the case manager:

  • the individual no longer needs services;
  • the individual is admitted to the hospital;
  • the individual is discharged from a hospital;
  • problems exist with family relationships that impact service delivery;
  • the individual is evicted or otherwise loses their housing that impacts service delivery;
  • the individual relocates;
  • the individual has an illness or injury that impacts service delivery; and
  • the individual loses Medicaid eligibility.

4100, Overview of CLASS Services Available Through the CDS Option

Revision17-1; Effective November 1, 2017

In the Community Living Assistance and Support Services (CLASS) program, the Consumer Directed Services (CDS) option is available to individuals who choose to self-direct one or more of the following program services:

  • CFC PAS/HAB;
  • CLASS transportation - habilitation;
  • in and out-of-home respite;
  • nursing (includes registered nursing, licensed vocation nursing, specialized registered nursing and specialized licensed vocational nursing);
  • employment assistance;
  • supported employment;
  • cognitive rehabilitation therapy;  
  • physical therapy;
  • occupational therapy; or
  • speech/language pathology.

When individuals select the CDS option, they are required to use Financial Management Services (FMS). Individuals may also access support consultation if it is determined to be a necessary support to assist the individual in successfully using the CDS option.

A Financial Management Services Agency (FMSA) chosen by the individual or legally authorized representative (LAR) provides FMS. FMS includes processing payroll and payables on behalf of the CDS employer. This includes serving as the CDS employer's fiscal/employer agent to ensure that federal, state and local employment taxes and labor and workers' compensation requirements are implemented in an accurate and timely manner. FMS also includes orientation, training, support and assistance with and approval of CDS employer budgets.

Support consultation is an optional service provided by a support advisor and provides a level of assistance and training beyond that provided by the FMSA through FMS. Support consultation helps a CDS employer to meet the required employer responsibilities of the CDS option and successfully deliver program services. Individuals may choose a support advisor from the list of support advisors who have met Texas Health and Human Services Commission (HHSC)  support advisor training requirements, located on the HHSC website at apps.hhs.texas.gov/providers/CDS/advisors.cfm. The FMSA must make a qualified support advisor available to individuals to whom they provide FMS. The CDS employer may choose to receive support consultation services from the support advisor associated with their FMSA or another qualified support advisor. Payment for support consultation is budgeted within the CDS portion of the individual's budget and is not a separate and distinct service on the Individual Plan of Care (IPC). Support consultation is available for CDS employers who choose additional support for hiring, dismissing, and training attendants. Support consultation provides more extensive training than CFC support management described below.

Community First Choice (CFC) support management offers training on how to select, manage, and dismiss an unlicensed service provider of CFC PAS/HAB. Support Management is a voluntary training benefit rather than a service. There is no reimbursement rate.  A Direct Services Agency (DSA) and a FMSA are required to offer support management. DSAs and FMSAs will provide the CFC Support Management Handout (PDF) |Spanish (PDF), along with a verbal explanation, to individuals whose service plan includes support management.

4110 Offering the CDS Option

Revision 17-1; Effective November 1, 2017

The individual's CLASS case manager at the case management agency (CMA), is required to offer the CDS option at the time of CLASS program enrollment, at least annually, and at any other time upon request of the individual or LAR.

Individuals have a choice in how their services are delivered:

  • Agency Option — The individual/LAR chooses to have a CLASS direct service agency (DSA) deliver their CLASS program services.
  • CDS Option — The individual/LAR serves as the employer of direct service providers for those CLASS program services chosen to be delivered through CDS.

The service delivery option individuals select is based on their own preferences, as discussed during the service planning process. It is important to tell individuals they may switch service delivery options at any time. It is possible to have some services delivered through the CDS option and have other services delivered through the agency option. If they select the CDS option, they can switch to the agency option at any time. However, if an individual switches from the CDS option to the agency option, they must wait 90 days before switching back to CDS.

The CLASS case manager offers the CDS option by reviewing the following HHSC forms with the individual.

Form 1581, Consumer Directed Services Option Overview — The purpose of Form 1581 is to introduce the CDS option. Form 1581 gives an overview of the differences between the CDS option and the agency option. This form, when signed, provides acknowledgement the CLASS case manager has provided, both orally and in writing, an overview of the benefits and responsibilities of the CDS option in CLASS.

  • If the individual chooses at this point to decline the CDS Option, the case manager completes Form 1584, Consumer Participation Choice, indicating the choice of the agency option. The case manager does not complete HHSC Form 1582, Consumer Directed Services Responsibilities, Form 1583, Employee Qualification Requirements, or Form 1586, Acknowledgement of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) Option.
  • If the individual wants to know more about the CDS option, the case manager continues to Form 1582.

Form 1582, Consumer Directed Services Responsibilities — The purpose of Form 1582 is to provide more detailed information to the individual or LAR about the responsibilities assumed if the CDS option is selected. It concludes with the CDS Consumer Self-Assessment. If the individual or LAR (the employer) is not able to complete the Consumer Self-Assessment, a person appointed by the employer to be the employer's Designated Representative (DR) must be able to complete the Consumer Self-Assessment for the individual receiving services to participate in the CDS option. Form 1720 designates a representative for employer duties. The purpose of the self-assessment is to:

  • assist the individual or LAR determine if they want to self-direct their services; and
  • determine what support might be needed for the individual/LAR to self-direct services.

The self-assessment may not be used to determine that an individual/LAR cannot use the CDS option. If the individual or their LAR has difficulty responding to the self-assessment questions, they probably will need a designated representative (DR) to help them implement the CDS option. It is the FMSA's responsibility to assist them with appointing a DR.

  • If the individual chooses at this point to decline the CDS option, the case manager completes Form 1584, indicating the choice of the agency option. The case manager does not complete HHSC Forms 1583 or 1586.
  • If the individual wants to know more about the CDS option, the case manager continues to Form 1583.

Form 1583, Employee Qualification Requirements — The purpose of Form 1583 is to provide important definitions of terms used with CDS. This form includes information about who can be the CDS employer, who can be a DR, and who can and cannot be hired as an employee in the CDS option for CLASS.

  • If the individual chooses at this point to decline the CDS option, the case manager completes Form 1584, indicating the choice of the agency option. The case manager does not complete HHSC Form 1586.
  • If the individual wants to select the CDS option, the case manager continues to Form 1584.

Form 1584, Consumer Participation Choice — The purpose of Form 1584 is to document the individual's/LAR's choice of service delivery option. If the individual or LAR is selecting the CDS option, the individual also must select an FMSA of his or her choice.

The case manager will provide a list of FMSAs serving the individual's CLASS catchment area. The FMSA choice list is available at apps.hhs.texas.gov/providers/cds/cdsas/CLASS.cfm.

To locate FMSAs serving the individual's local area, type in the county in which the individual resides. The case manager should encourage the individual or LAR to call and interview several FMSAs before selecting one.

Important: FMSAs are not required to be located in the same town in which the individual resides. FMSAs provide FMS. This service does not require ongoing face-to-face contact. While FMSAs are required to make one visit to the individual's home to conduct the CDS orientation before service initiation, the FMSA conducts the remainder of their business via email or fax with the individual or LAR, or DR if one has been appointed.

Form 1586, Acknowledgement of Information Regarding Support Consultation Services — The purpose of Form 1586 is to provide information to the individual or LAR regarding the availability of support consultation in the CLASS program. The use of support consultation is optional. If the individual or LAR requests support consultation during the service planning process, this service must be included in the IPC. During the development of the IPC, the number of units of support consultation must be determined for inclusion in the IPC. The amount and duration of support consultation needed by the individual will vary. Since payment for support consultation is drawn from the CDS employer's service budget, there are no additional funds available to pay for support consultation.

Support consultation provides practical skills training, coaching, and assistance related to employer responsibilities, including:

  • principles of self-determination;
  • recruiting, screening and hiring workers;
  • completing documents and assessments required to employ a person, retain a contractor or vendor, and manage service providers;
  • negotiating service agreements, including pricing and scheduling services, goods and items;
  • effective communication, decision-making and problem-solving skills to meet employer responsibilities ;
  • tools for accessing information, resources and assistance;
  • contacting appropriate people or entities based on their roles, responsibilities and eligibility related to the individual's program or the CDS option;
  • participating in service planning team (SPT) meetings at the employer's request; and
  • complying with requirements of the individual's program as related to services delivered through the CDS option.

A support advisor provides support consultation. FMSAs are required to make support advisors available through their agency.

The individual or LAR may select a qualified support advisor provided by his or her FMSA, or may opt to choose a certified support advisor who is not associated with the FMSA from the list of qualified support advisors.

The list of support advisors who completed the required support advisor training is available on the HHSC website at apps.hhs.texas.gov/providers/CDS/advisors.cfm.

Form 1720Appointment of a Designated Representative

The purpose of Form 1720 is to appoint a representative to perform specific employer tasks delegated by the Individual or LAR. The individual or LAR will choose a designated representative to perform certain employer tasks. If the designated representative is not a relative, the FMSA must conduct a criminal conviction check using the Texas Department of Public Safety public website.

Form 1735, CLASS, Service Provision Requirements Addendum

The purpose of Form 1735 is to provide program specific information about the services that can be self-directed, the provider qualifications, service delivery documentation and training requirements. By signing and dating Form 1735-CLASS, the CDS employer (individual or LAR) or DR certifies that they have read, understood, and agreed to comply with the CLASS program requirements.

4120 Service Backup Plans

Revision 17-1; Effective November 1, 2017

The CDS employer (individual or LAR) is responsible for developing a backup plan for self-directed CFC PAS/HAB and nursing services. CLASS Transportation - Habilitation  services do not require a service backup plan. CDS service backup plans are documented on Form 1740, Service Backup Plan. The CDS employer's plan must be reviewed and approved by the SPT.

It is the case manager's responsibility during each IPP Service Review to review a CDS employer's backup plan to determine whether the strategies are reasonable and viable contingencies in the event an individual is unable to receive a critical program service by their regular service provider. If the case manager determines the strategies are not reasonable and viable, the case manager may support the CDS employer as needed to develop a viable plan. The case manager may also suggest the CDS employer consider using support consultation to assist in the development of a backup plan.

The CDS employer is responsible for providing the FMSA with the copy of each service backup plan within five working days after it has been approved by the SPT.

Backup plan strategies may include both formal and informal supports. If backup services are to be purchased from a CLASS DSA, the CDS employer must include such costs in the CDS budget. In addition, people who are paid to provide backup services must pass all criminal history and registry checks. Funds must be allocated in the individual's budget for criminal history checks of backup service providers.

4130 Service Planning

Revision 17-1; Effective November 1, 2017

The SPT consists of the case manager, the applicant/individual/LAR, DSA representative(s), and other people requested by the applicant/individual/LAR to develop a proposed IPC, using Form 3621, CLASS/CFC – Individual Plan of Care. The FMSA does not play a role in the CLASS service planning process. FMSA staff does not attend SPT meetings, unless requested by the individual. The CDS employer is responsible for developing the PAS/Habilitation Plan - CLASS/DBMD/CFC in conjunction with the SPT. Any change in the amount of a service delivered through the CDS option must be discussed and justified by the SPT as part of the SPT process.

HHSC may, at any time, request documentation to justify a service. If HHSC requests this documentation for a service the individual or LAR has chosen to self-direct using the CDS option, the CDS employer is responsible for providing the documentation to HHSC. The CDS employer may request support from the case manager to provide this documentation for HHSC.

The SPT must revise the IPC to include any change in the amount of a service(s). For all IPC revisions, the case manager must provide a copy of the IPC to the FMSA within five business days of HHSC transmission of the authorized IPC, as evidenced by the fax transmittal date on the documents.

A support advisor may participate in service planning meetings if requested by the individual or LAR. A support advisor must notify the individual's case manager:

  • when support consultation service goals have been met;
  • if the person receiving support consultation is unable or unwilling to cooperate with service delivery; or
  • of the progress and status of the consumer-directed service required by the individual's program.

The individual or LAR (that is, "employer") is responsible for:

  • ensuring service delivery activities are in accordance with the individual's service plan and justification for the CDS service; and
  • ensuring service delivery documentation is accurate.

A support advisor may provide coaching in any of the areas listed above.

4200, Enrolling the Individual in the Consumer Directed Services Option

Revision 17-1; Effective November 1, 2017

To enroll an individual in the CDS option, the case manager sends the following documents to the FMSA:

  • a completed Form 1584, Consumer Participation Choice, within five business days after the individual or LAR selects the CDS option;
  • a copy of the completed PAS/Habilitation Plan - CLASS/DBMD/CFC schedule; and
  • a copy of the completed proposed IPC when it is sent to HHSC for authorization.

The FMSA needs the proposed IPC in order to conduct the required CDS orientation with the individual or LAR before services delivered via the CDS option can begin.

During the CDS orientation, several key activities must occur before services starts. The FMSA will:

  • explain the hiring process to the employer, including the required criminal history, registry and Medicaid exclusion checks;
  • ensure the employer understands who can and cannot be hired to provide CLASS services under the CDS option (e.g., CFC PAS/HAB or CLASS habilitation, respite, nursing, physical therapy, occupational therapy or speech/language pathology);
  • work with the employer to develop the draft CDS budget, which includes the hours direct service providers will work, wage rate and benefits for each employee hired and project expenditures for employer services and supports, including support consultation if included on the IPC (the draft CDS budget is based on the proposed IPC); and
  • explain service delivery documentation must relate back to the individual's plan of care and justification for each CLASS service.

The FMSA will need to know the number of hours of CFC PAS/HAB or CLASS habilitation, respite, nursing, physical therapy, occupational therapy, speech/language pathology or support consultation on the proposed IPC in order to assist the employer with development of the CDS budget. The FMSA conducts the CDS orientation while the proposed IPC is under review by HHSC.

The FMSA is required to notify the case manager via HHSC Form 2067, Case Information when the orientation has been completed. The case manager files the form in the individual's record.

Services delivered through the CDS option may not begin until:

  • the in-person CDS orientation has been completed;
  • direct service provider eligibility has been determined and verified by the FMSA;
  • the service provider agreement(s) has been signed;
  • the CDS budget has been approved by the FMSA; and
  • the IPC has been authorized by HHSC.

HHSC notifies the CMA in writing of whether the proposed IPC is authorized. The case manager must then provide the FMSA with a copy of the HHSC authorized IPC. In the event the number of hours authorized for a CDS service changes as a result of HHSC review, the case manager will notify the FMSA of the change by sending Form 2067 to the FMSA so that adjustments can be made to the individual's CDS budget as necessary.

Financial Management Services (FMS)

For individuals who use the CDS option, the IPC must include FMS. FMS is authorized as a monthly service. For example, for a 12-month period, 12 units of FMS must be included on the IPC.

Support Consultation

If the individual or LAR requests support consultation or the individual's SPT determines support consultation would be beneficial to provide employer coaching, hours for support consultation must also be included on the IPC.

Support consultation is to be used, as needed. On average, an individual may be authorized for six to nine hours of support consultation per year. It is generally not the type of service to be used on a weekly basis.

Note: A CLASS DSA is not responsible for delivering or billing for a service delivered through the CDS option.

If the individual or LAR decides to receive nursing through the CDS option, the DSA is not responsible for supervising or verifying the credentials of the nurse hired by the CDS employer.

4300, Monitoring Consumer Directed Services

Revision 17-1; Effective November 1, 2017

The case manager monitors CDS services in the same manner as CLASS services delivered through the agency option. A key monitoring role is to determine whether the individual's health and safety is at risk in the environments in which the individual receives CLASS, CFC, and non-CFC/CLASS services and, if necessary, to take action to protect the individual's health and safety. If the case manager learns of a problem with the FMSA, the case manager may report the FMSA to Consumer Rights and Services at HHSC. More detailed information regarding consumer rights and services may be found in Section 1200, Interest List.

The FMSA is required to provide the case manager and CDS employer quarterly reports of expenditures for each CDS. The purpose of these reports is to determine over or under utilization of services. The FMSA will also note any areas of non-compliance with the CDS option on the quarterly report.

4400, Corrective Action Plans

Revision 13-2; Effective September 6, 2013

Based on review of the quarterly reports or a monitoring visit, the case manager may request a corrective action plan from the employer. It is important to remember it is the CDS employer's responsibility, not the FMSA's, to ensure services are delivered, services are provided in accordance with the service plan, and program rules are being followed.

At the request of the case manager or the FMSA, the CDS employer must develop a corrective action plan using Form 1741, Corrective Action Plan. The person requesting the corrective action plan completes the top part of the form indicating the specific reason a corrective action plan is needed (for example, over expenditure or failure to submit required documentation to the FMSA in a timely manner). The CDS employer completes the corrective action strategies section of the form. The CDS employer must provide a written corrective action plans to the person requiring the plan within 10 calendar days after receiving the request. The CDS employer's plan must be reviewed for feasibility and signed by the SPT. It is the case manager's responsibility to review a CDS employer's corrective action plan to determine whether the resolution proposed in the plan represents a reasonable and viable solution to the identified problem. If the case manager determines the resolution proposed in the plan is not a reasonable and viable solution to the identified problem, the case manager may support the CDS employer as needed to develop a viable plan. The case manager may also suggest the CDS employer consider using support consultation to assist in the development of a corrective action plan.

Corrective action plan information needs to be specific to the identified issue and identify specific strategies and time frames for improvement. The goal of a corrective action plan is to focus on needed supports to ensure the employer succeeds in using the CDS option.

4500, Termination from the CDS Option

Revision 13-2; Effective September 6, 2013

An individual or LAR may voluntarily request to switch from the CDS option to the provider-managed option. An individual must remain with the provider-managed option for at least 90 days before requesting to transfer back to the CDS option.

The SPT may recommend the individual be involuntarily terminated from the CDS option. For an individual participating in CDS, the case manager must recommend DADS terminate the individual's participation in the CDS option if the case manager determines:

  • the individual's continued participation in CDS poses a significant risk to the individual's health, safety or welfare;
  • the individual or LAR has not complied with the CDS rules in Title 40, Texas Administrative Code, Chapter 41, Subchapter B, Responsibilities of Employers and Designated Representatives; or
  • the employer failed to implement a corrective action plan within required time frames.

Before an FMSA recommends involuntary termination of participation in the CDS option to an individual's case manager, the FMSA must:

  • provide documentation to the individual's case manager of additional and ongoing training and supports provided by the FMSA when an employer or DR demonstrates noncompliance with employer responsibilities;
  • provide assistance requested by the employer or DR to develop and implement a corrective action plan;
  • provide documentation of any corrective action plan required of the employer or DR by the FMSA in accordance with §41.221, Corrective Action Plans; and
  • notify the case manager in writing in accordance with the requirements of the individual's program when recommending termination of an individual's participation in the CDS option.

On receipt of a recommendation for involuntary termination from the FMSA or other party, the individual's case manager must:

  • provide assistance with accessing supports and developing and implementing a corrective action plan related to non-compliance with program and CDS requirements;
  • document interventions used by the individual, employer or DR to eliminate non-compliance with program requirements for delivery of program services through the CDS option; and
  • convene the SPT to:
    • consider recommendations related to the individual's participation in the CDS option;
    • recommend additional interventions to be implemented to protect the individual's health and welfare for continued participation in the CDS option; and
    • make revisions to the individual's service plan, if needed.

If the SPT recommends terminating an individual's participation in the CDS option and the individual is receiving other CLASS services from a CLASS DSA, the case manager must:

  • request the FMSA submit to DADS Form 3621-T, CLASS/CFC – IPC Service Delivery Transfer Worksheet, documenting the number of service units and the amount of funds to be transferred to the CLASS DSA;
  • revise the Individual Program Plan (IPP) to reflect all services will be provided by the DSA;
  • work with the DSA as necessary to revise the IPC to remove FMS and support consultation and adjust the remaining funds for the services being moved to the provider-managed option, submitted by the FMSA; and
  • submit a written request to DADS to involuntarily terminate the CDS option that includes:
    • a description of the service component(s) recommended for termination;
    • a statement of the reasons why termination is recommended, including failure by the employer to implement the CDS corrective action plan (Form 1741, Corrective Action Plan);
    • a copy of the CDS corrective action plan (Form 1741) describing the employer's attempts to resolve the issues before termination was recommended; and
    • a copy of the revised IPC.

The case manager will notify the FMSA (using Form 2067, Case Information) a request to terminate the CDS option has been sent to DADS for approval.

4600, Transfers from One FMSA to Another

Revision 13-2; Effective September 6, 2013

An individual or LAR may transfer to a new FMSA at any time. Upon request, the case manager will provide a list of FMSAs serving the individual's CLASS catchment area to the individual or LAR. The FMSA choice lists are on the DADS website at apps.hhs.texas.gov/providers/cds/cdsas/CLASS.cfm.

To locate FMSAs serving the individual's local area, select the county in which the individual resides. The case manager should encourage the individual or LAR to call and interview several FMSAs before selecting one.

4610 Transferring FMSA

Revision 17-1; Effective November 1, 2017

The transferring FMSA must provide the case manager with the current balance of each service category based on most current IPC authorized and actual delivery up to the transfer effective date (Form 3621-T, CLASS/CFC – IPC Service Delivery Transfer Worksheet). The total number of service units provided before the effective date of the transfer is the sum of the number of service units:

  • provided and paid;
  • provided that have been billed but not yet paid; and
  • to be provided until the transfer effective date.

Within five calendar days of notification by the case manager of the individual's decision to transfer to a different FMSA this information must be delivered to the receiving FMSA.

4620 Receiving FMSA

Revision 13-2; Effective September 6, 2013

The receiving FMSA's responsibilities start on the transfer effective date, as identified on Form 3621-T, CLASS/CFC – IPC Service Delivery Transfer Worksheet. The total number of service units available to the individual after having selected the receiving FMSA is the number of service units to be provided from the transfer effective date until the end of the IPC effective period.

Note: FMSAs are not required to be located in the same town in which the individual resides. FMSAs provide FMS. This service does not require ongoing face-to-face contact. While FMSAs are required to make one visit to the individual's home to conduct the CDS orientation before service initiation, the FMSA conducts the remainder of its business via e-mail or fax with the individual or LAR, or the DR if one has been appointed.

4630 Services in the CLASS Programs Available Through the CDS Option that may be Received Outside of the State of Texas

Revision 17-1; Effective November 1, 2017

An individual in the CLASS Program may receive only the following services through the CDS option while the individual is temporarily staying at a location outside the state of Texas:

  • community first choice personal assistance services/habilitation (CFC PAS/HAB);
  • registered nursing;
  • licensed vocational nursing;
  • specialized registered nursing;
  • specialized licensed vocational nursing; and
  • out-of-home respite in a camp setting.

Time Limit on Receiving Services Outside of the State of Texas

An individual in the CLASS Program may receive services listed above through the CDS option while the individual is temporarily staying at a location outside of the State of Texas for no more than 30 calendar days within a service plan year.

Notifications to the Case Manager and FMSA from the CDS Employer

If an individual wants to receive a service through the CDS option while the individual is temporarily staying at a location outside the State of Texas, a CDS employer must, at least five working days before the individual leaves the state, send written notification to the individual’s case manager and FMSA stating the individual is temporarily staying at a location outside the state. If circumstances beyond the CDS employer’s control do not permit the notification to be sent within the five-day time frame, the CDS employer must, at least 24 hours before the individual leaves the state, send written notification to the individual’s case manager and FMSA stating the individual is temporarily staying at a location outside the state.

The written notification must include:

  • the name of the individual who will be receiving a service outside the state of Texas;
  • the type of service the individual will be receiving;
  • the date the delivery of the service will begin;
  • the specific location where the individual will be receiving the service;
  • the length of time the individual is expected to be outside the state of Texas which may be no more than 30 calendar days within a service plan year;
  • contact information for the individual or legally authorized representative while the individual is outside the state of Texas;
  • a copy of a completed HHSC Form 1739, CDS Service Provider Agreement, for the service provider who will be providing the service outside the state of Texas; and
  • an acknowledgement stating the employer and service provider will follow applicable HHSC;
  • rules while providing services outside the state of Texas.

Within three working days after the individual's return to the individual’s residence in Texas, the employer must notify the individual's case manager and FMSA, by phone or in writing, of the individual’s return. The FMSA and case manager must keep the notifications required above in the individual’s record.

If a CDS employer does not comply with the notification requirements described above, the CDS employer may be required to develop a corrective action plan in accordance with HHSC rule at Texas Administrative Code (TAC), Title 40, §41.221.

More information on this option is available in Information Letter No. 16-35 – Receiving Services Outside the State of Texas in the CLASS and DBMD Programs.

4700, CDS Resources

Revision 17-1; Effective November 1, 2017

The CDS rules are available on the Secretary of State's website at http://texreg.sos.state.tx.us/public/readtac$ext.ViewTAC?tac_view=4&ti=40&pt=1&ch=41.

CDS Frequently Asked Questions is at hhs.texas.gov/doing-business-hhs/provider-portals/long-term-care-providers/consumer-directed-services-cds/how-cds-works. CDS brochure is at hhs.texas.gov/sites/default/files/documents/doing-business-with-hhs/providers/long-term-care/cds/cds-faqs.pdf.

CDS Roles and Responsibilities Chart is at hhs.texas.gov/doing-business-hhs/provider-portals/long-term-care-providers/consumer-directed-services-cds/implementing-cds.

Additional information regarding CDS may be found at hhs.texas.gov/doing-business-hhs/provider-portals/long-term-care-providers/consumer-directed-services-cds/cds-training-presentations.

Form Resources

As part of the CDS option, the following forms may need to be completed:

  • Form 1581, Consumer Directed Services Option Overview
  • Form 1582, Consumer Directed Services Responsibilities
  • Form 1583, Employee Qualification Requirements
  • Form 1584, Consumer Participation Choice
  • Form 1586, Acknowledgement of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) Option
  • Form 1720, Appointment of a Designated Representative
  • Form 1735, CLASS, Service Provision Requirements Addendum
  • Form 1740, Service Backup Plan
  • Form 1741, Corrective Action Plan
  • Form 2067, Case Information
  • Form 3596, PAS/Habilitation Plan - CLASS/DBMD/CFC
  • Form 3621, CLASS/CFC – Individual Plan of Care
  • Form 3621-T, CLASS/CFC – IPC Service Delivery Transfer Worksheet
  • Form 3629, Individual Program Plan Addendum
  • Form 8606, Individual Program Plan (IPP)

5100, Overview

Revision 17-1; Effective November 1, 2017

At the Texas Health and Human Services Commission (HHSC)’s discretion, the Community Living Assistance and Support Services (CLASS) staff conducts UR of an Individual Plan of Care (IPC) to determine if:

  • the IPC meets the justification for services criterion as outlined in the CLASS/CFC program rules;
  • CLASS/CFC services as a whole enhance an individual's integration in the community and prevent admission to an institution while maintaining and improving independent functioning; and
  • the CLASS/CFC services specified in the IPC meet the following requirements:
      • are necessary to protect the individual's health and welfare in the community;
      • address the individual's related condition;
      • are not available to the individual through any other source, including the Medicaid state plan, other governmental programs, private insurance or the individual's natural supports;
      • are the most appropriate type and amount of CLASS/CFC program services to meet the individual's needs;
      • are cost effective;
      • meet the requirements relating to adaptive aids and minor home modifications, as outlined in Appendix I, Adaptive Aids and Appendix II, Minor Home Modification Services; and
      • is not receiving an excluded service as identified in Appendix III, Mutually Exclusive Services.

If requested by HHSC, a CLASS/CFC program provider must submit additional documentation supporting the IPC to HHSC within 10 calendar days after being requested.

If HHSC determines the IPC does not meet the justification for services criterion, HHSC:

  • notifies the individual's case management agency (CMA) and direct services agency (DSA) of such determination;
  • sends written notice to the individual or legally authorized representative (LAR) the individual's CLASS/CFC services are proposed for termination; and
  • includes in the notice the individual's right to request a fair hearing.

If HHSC determines one or more of the CLASS/CFC services specified in the IPC do not meet the requirements for an IPC, HHSC:

  • denies or reduces the service(s), as appropriate;
  • modifies and authorizes the IPC; and
  • notifies the individual's CMA, in writing, of the action taken.

If HHSC notifies the CMA of the denial or reduction of a CLASS/CFC service, see Section 2400, Denial, Reduction, Suspension and Termination.

If the individual or LAR requests a fair hearing before the effective date of the reduction of a CLASS/CFC service, as specified in the written notice, the DSA must provide the service to the individual in the amount authorized in the prior IPC while the appeal is pending.

The IPC effective period of an enrollment IPC or a renewal IPC modified by HHSC does not change as a result of HHSC' modification.

5200, CLASS Cost Limits

Revision 17-1; Effective November 1, 2017

This section describes utilization review (UR)  cost limits and service limits employed during review of a proposed IPC. HHSC may, at its discretion, select any proposed IPC for UR, regardless of total cost of services. HHSC selects a proposed IPC for UR at its discretion any time the agency receives a proposed IPC and will verify the IPC does not exceed the CLASS cost ceiling of $114,736.07. CLASS UR also verifies that CLASS services do not exceed a maximum combined cost of $10,000 for adaptive aids and dental treatment and $10,000 for minor home modifications. The IPC must not include more than 30 days of in-home respite and out-of-home respite combined. CFC services, which are subject to utilization review, are not included when verifying the cost ceiling is not surpassed.

As necessary, HHSC will coordinate with the individual's CMA to request additional justification information for proposed services and amounts of services included in an individual's proposed IPC as part of the UR process. The CMA is responsible to respond to HHSC’s UR requests in accordance with the CLASS rule in Title 40 of the Texas Administrative Code (TAC), §45.214. The CMA must submit any requested additional documentation supporting the proposed IPC to HHSC within 10 calendar days after HHSC’s request.

5300, Dental Utilization Review of Dental Services

Revision 17-1; Effective November 1, 2017

HHSC may choose to use a Texas licensed dentist to review a CLASS IPC that includes dental services to obtain needed expert opinion. HHSC staff may consult with a licensed dentist concerning dental services proposals if:

  • the cost of dental treatment exceeds a $2,000 limit;
  • a decision regarding medical need is required;
  • a determination regarding cost effectiveness is needed; or
  • a determination if the dental service requested is an allowable service.

The dentist identified by HHSC to perform dental UR may request additional items (e.g., x-rays, etc.) from the dentist who developed the dental treatment plan, as necessary. The HHSC dentist may contact the treating dentist by telephone, or by using secure e-mail if it is a matter of missing information or clarification. HHSC staff will keep a record of any additional information requested by the HHSC dentist to perform dental UR from the treating dentist, as well as the rationale provided by the HHSC dentist for denying or approving the request.
The HHSC dentist may make cost effectiveness determinations based on the most recently issued version of the Survey of Dental Fees published by the American Dental Association (ADA).

6000, Contract Monitoring

Revision 17-1; Effective November 1, 2017

Federal regulations require the Texas Health and Human Services Commission (HHSC) to assure necessary safeguards are taken to protect the health, safety and welfare of individuals in the Community Living Assistance and Support (CLASS) program. HHSC conducts contract and fiscal compliance monitoring reviews to ensure providers meet all requirements for participation in the CLASS program.

6100, Contract Monitoring

Revision 17-1; Effective November 1, 2017

A contract and fiscal compliance monitoring review is a systematic review of a contractor's financial, personnel and individual service records to determine compliance with CLASS program and contract requirements.

  • CLASS program providers are monitored during the 14th or 15th month of the provisional contract term.  Depending upon the results of the formal provisional monitoring, HHSC will monitor the CLASS program provider within 13 to 24 months from the exit date of the formal provisional monitoring and, at a minimum, every 24 months thereafter. 

HHSC randomly selects a sample that includes 5% of the individuals being served by the contracted provider before the review. A minimum of four individuals will be reviewed unless the program provider is serving three or fewer individuals. If the program provider is serving three or fewer individuals, HHSC will review all of the individuals being served HHSC does not provide the sample list before the entrance conference.

HHSC will conduct a contract monitoring review onsite at the physical location identified in the contract. HHSC notifies the program provider of an onsite monitoring review with written notice at least 14 calendar days before the review, which includes:

  • the date and time HHSC staff plan to arrive at the review site and conduct the entrance conference;
  • the number of HHSC staff to conduct the review;
  • the approximate number of days necessary to complete the review;
  • location at which HHSC will conduct the review; and
  • the time period to be reviewed.

The program provider must provide:

  • specific records necessary for the review, as requested by HHSC;
  • adequate work space for the number of HHSC staff specified in the notification;
  • lighting, heating and cooling consistent with that provided to provider staff; and
  • copies or access for HHSC staff to make copies of documents during the course of the review.

HHSC staff conducts an entrance conference at the beginning of the monitoring review to discuss:

  • the purpose of the visit;
  • what will be reviewed;
  • estimated length of time it will take to conduct the review;
  • records needed to complete the review; and
  • the program provider's contact person during the review.

The provider's documentation is reviewed for program and fiscal compliance. If any financial errors are found, HHSC may require the provider to submit documentation of negative billing to correct these errors.

Upon completion of the monitoring review, HHSC staff conducts an exit conference to:

  • review findings identified during the monitoring review;
  • provide the compliance score;
  • provide fiscal monitoring results;
  • explain if a corrective action plan (CAP) is required or if the findings will be forwarded to the Sanction Action Review Committee (SARC);
  • discuss the need for an immediate corrective action plan, if applicable;
  • inform the provider of its right to an administrative review of the methodology employed by the review team if the provider agency has reason to suspect the monitoring review was not conducted in accordance with HHSC policies and procedures; and
  • inform the provider of the right to a formal appeal of recoupment.

A provider must attain a minimum compliance level of 90% or above. If a provider attains an overall compliance level of 90% or more, but scores less than 90% on any individual standard, the provider is required to submit a CAP for the standards for which it scored less than 90%. If the overall compliance score is below 90%, HHSC determines the provider to be out of compliance and may submit a referral to the SARC.

HHSC, at its discretion and upon the SARC recommendation, may apply the following sanctions, including:

  • CAP;
  • referral hold;
  • vendor hold; and
  • contract termination.

7100, Billing and Claims Payment

Revision 20-4; Effective October 9, 2020

The following services may be billed under the Community Living Assistance and Support Services (CLASS) Program:

  • Case Management
  • Community First Choice (CFC) PAS/HAB
  • Transportation-habilitation Services
  • Supported Employment
  • Employment Assistance
  • Prevocational Services
  • Nursing Services (e.g., registered nursing, licensed vocational nursing, specialized registered nursing, specialized licensed vocational nursing)
  • Physical Therapy
  • Occupational Therapy
  • Speech and Language Pathology
  • Specialized Therapies, that include:
    • Massage Therapy
    • Recreational Therapy
    • Music Therapy
    • Aquatic Therapy
    • Hippotherapy
    • Therapeutic Horseback Riding
    • Auditory Enhancement Training
  • Dietary Services
  • Behavioral Support
  • Cognitive Rehabilitation Therapy
  • Support Family Services
  • Continued Family Services
  • Transition Assistance Services
  • Respite
  • Adaptive Aids (vehicle modifications are billed as adaptive aids)
  • Dental Services
  • Minor Home Modifications
  • Services specifically for individuals who choose the Consumer Directed Services (CDS) option that include:
    • Financial Management Services
    • Support Consultation

Note: For purposes of this section, the term "provider agency" means a CLASS Case Management Agency (CMA) or Direct Service Agency (DSA), as applicable.

Each DSA must ensure that each CLASS program service is provided to an individual in accordance with Appendix C of the CLASS Waiver Application. The approved service definition for each of the services described in this section are contained within the Texas Administrative Code (TAC). Those service definitions are located in 40 TAC §45.103, Definitions.

Each CLASS service delivered to an individual must be recorded as a distinct event by each service provider. Documentation of services delivered may be provided on Form 3625, CLASS/CFC – Documentation of Services Delivered, by fax or via the Electronic Visit Verification (EVV) System.

Service delivery documentation must be completed according to the Texas Health and Human Services Commission (HHSC) instructions.

Each provider agency must designate a timekeeper to sign Form 3625 to verify its accuracy.

For CLASS services requiring EVV, providers must follow EVV billing requirements for relevant claims. Providers may refer to HHSC's EVV website for more information.

CLASS payment rates are set by the HHSC Rate Analysis. For current rates, see https://pfd.hhs.texas.gov/.

7110 Case Management Agency (CMA) Services

Revision 17-1; Effective November 1, 2017

Case management services provided after the individual has been enrolled in the CLASS program are based on a monthly rate. The number of case management units needed by the individual are determined by the service planning team (SPT) and approved by HHSC on the Individual's Plan of Care (IPC). The monthly case management fee may only be billed during a month when a billable contact has occurred. The case manager must record time spent providing case management services on Form 3625, CLASS/CFC – Documentation of Services Delivered.

If the individual/LAR requests a fair hearing before the effective date of the termination, as specified in the written notice of CLASS Program services and CFC services, the CMA must continue to provide services to the individual.

7120 Direct Services Agency (DSA) Services

Revision 17-1; Effective November 1, 2017

If the individual/LAR requests a fair hearing before the effective date of the termination of CLASS Program services and CFC services, as specified in the written notice, the DSA must continue to provide services to the individual in the amounts authorized in the IPC while the appeal is pending.

7121 Personal Service Agreement or Contract with Another Agency

Revision 17-1; Effective November 1, 2017

With the exception of CFC PAS/HAB, transportation-habilitation and in-home respite, the DSA may contract with an individual or agency to provide CLASS services. The DSA is responsible for ensuring all service providers meet required direct service provider qualifications and training requirements.

CLASS services provided through a personal service agreement or contract with the DSA must be recorded on Form 3625, CLASS/CFC – Documentation of Services Delivered, or by fax and authenticated by the service provider.

7122 Minor Home Modifications and Adaptive Aids

Revision 17-1; Effective November 1, 2017

The DSA will only be reimbursed for adaptive aids and minor home modifications included in Appendix I, Adaptive Aids, and Appendix II, Minor Home Modification Services, and authorized by HHSC on the individual's IPC. Minor home modifications and adaptive aids purchased by the DSA must be recorded on Form 3625, CLASS/CFC – Documentation of Services Delivered, and signed by the appropriate representative of the DSA. The DSA representative must be a:

  • program director or meet program director qualifications;
  • registered nurse (RN); or
  • licensed vocational nurse (LVN).

The DSA must have a signed and dated invoice from the vendor indicating work performed and/or services delivered and the date of completion. The DSA must keep required documentation related to procurement and cost.

7200, Billable Activities

Revision 11-1; Effective June 13, 2011

7210 Case Management

Revision 17-1; Effective November 1, 2017

The following activities are billable and must include a face-to-face or telephone contact with the individual/LAR:

  • assessing the individual's needs;
  • enrolling the individual into the CLASS Program;
  • developing the individual's service plan;
  • coordinating the provision of CLASS services;
  • monitoring the effectiveness of the CLASS services and the individual's progress toward achieving the outcomes identified;
  • revising the individual's service plan, (limited to time spent meeting with the SPT);
  • accessing non-waiver services, including Medicaid State Plan services;
  • resolving crisis situations in the individual's life;
  • advocating for the individual; and
  • pre-enrollment assessment before the individual is enrolled in the CLASS program.

Note: A face-to-face or telephone contact with the paid caregiver (e.g., CFC PAS/HAB, transportation-habilitation staff, respite care provider, nurse, etc.) does not establish a billable activity.

Effective March 20, 2016, each case manager must have at least one face-to-face or telephone contact with the individual or LAR or other persons acting on behalf of the individual, such as an advocate or family member, per month to provide case management. Case management in the CLASS program is paid a monthly rate based on at least one billable contact. The CMA must ensure the service date billed for this contact agrees with the date of the actual billable contact.

Case management billing must be documented on Form 3625, CLASS/CFC – Documentation of Services Delivered, and supported by documented contact notes that include:

  • the date of contact;
  • the description of the case management provided;
  • the progress or lack of progress in achieving goals or outcomes in observable/measurable terms that directly relate to the specific goal or objective addressed;
  • the person with whom the contact occurred; and
  • the case manager who provided the contact.

7220 Nursing

Revision 11-1; Effective June 13, 2011

The following activities may be billed under the CLASS program if included in the individual's approved IPC:

  • direct delivery of nursing services by an RN or LVN within the scope of their licensure;
  • delegation activities performed by the RN, including the direct training and supervision of unlicensed persons in the performance of health-related tasks;
  • nursing assessments performed by the RN; and
  • participation on the SPT when the individual has an identified need for nursing services.

7221 Specialized Nursing

Revision 11-1; Effective June 13, 2011

Nursing services provided to an individual who requires tracheostomy care or is ventilator dependent must be billed to the CLASS program if included in the individual's authorized IPC.

7230 Therapies

Revision 22-3; Effective Oct. 25, 2022

HHSC authorizes providers to submit claims for reimbursement of therapy services delivered by telehealth (synchronous audio-visual technology). Per standards of care, telehealth must be clinically appropriate, safe, and agreed to by the person receiving services or by the legally authorized representative (LAR). Verbal consent is permissible and should be documented in the person’s record. Telehealth may require participation of a parent or caregiver to assist with the treatment. Providers must be able to defer to the needs of the person receiving services, allowing the mode of service delivery (audio-visual or in-person) to be accessible, person and family centered, and primarily driven by the person’s choice and not provider convenience.

Telehealth therapy services must be delivered within the provision of current licensure requirements and must be determined clinically appropriate by the rendering therapist. The use of phone (audio-only) delivery is only permitted for therapy services that are provided to the person’s LAR or others involved in their care such as a caregiver or family member. These services should correspond to allowed billable activities as stated under each therapy section.

Providers must use modifier 95 to indicate remote delivery. Form 3625’s comment section should indicate that remote delivery of the service is clinically appropriate per the rendering therapist’s professional judgement.

7231 Behavioral Support Services

Revision 22-3; Effective Oct. 25, 2022

Behavioral support services are specialized interventions that assist a person in increasing adaptive behaviors and replacing or modifying challenging or socially unacceptable behaviors that prevent or interfere with the person’s inclusion in the community.

A program provider must ensure the behavioral support services provider is a:

  • licensed psychologist;
  • provisionally licensed psychologist;
  • licensed psychological associate;
  • licensed clinical social worker;
  • licensed professional counselor; or
  • behavior analyst certified by the Behavior Analyst Certification Board, Inc.

The behavioral support services provider must have received training in behavioral support or have experience in providing behavioral support. The DSA may document a behavioral support provider's compliance with this requirement by listing any training related to behavioral support the provider has completed. The DSA program director or RN may also document observation of positive outcomes for any person receiving behavioral support services. The DSA may also document observation of the behavioral support provider by successfully completing the billable tasks listed below.

The following activities may be billed under the CLASS program if included in the person's authorized IPC:

  • conducting a functional behavior assessment;
  • developing an individualized behavior support plan;
  • training and consulting with an individual, family member, or other people involved in the individual's care regarding the implementation of the behavior support plan;
  • time spent collaborating with the person, LAR, primary caregiver, or service provider to transition the services to a non-therapist, changing the role of the therapist to a supervisory role;
  • monitoring and evaluating the effectiveness of the behavior support plan;
  • modifying, as necessary, the behavior support plan based on monitoring and evaluating the plan's effectiveness; and
  • counseling and educating an individual, family members, or other people involved in the individual's care about the techniques to use in assisting the individual to control challenging or socially unacceptable behaviors.

The behavioral support provider must provide justification for time required to develop an individualized behavior support plan. The justification should include time necessary to conduct the functional assessment, any review of individual records, and time spent developing an individualized behavior support plan.

7232 Occupational Therapy, Physical Therapy, and Speech and Language Pathology

Revision 22-3; Effective Oct. 25, 2022

A current physician's order for each therapy is required before the delivery of occupational therapy, physical therapy and speech and language pathology. Physician's orders are not necessary for an evaluation.

The following activities may be billed under the CLASS program if included in the person’s authorized Individual Plan of Care:

  • interacting in-person or by synchronous audio-visual technology with the person;
  • time spent by a therapist to train the person or legally authorized representative, primary caregiver or service provider in the proper use of an adaptive aid;
  • time spent teaching a service provider to reinforce therapy goals during activities of daily living (ADL);
  • time spent by a therapist to perform face-to-face evaluations to determine a person’s need for skilled therapy service, adaptive aids or minor home modifications; and
  • participation on the SPT may be billed as a professional service, only:
    • when the person has an identified need for the service; and
    • for actual time spent in the capacity of the respective discipline.

The therapist must provide justification for time required to develop an assessment of the person's need for an adaptive aid or minor home modification. The justification should include time necessary to conduct the assessment and research regarding the most appropriate and cost-effective manner to meet the person's needs.

7233 Specialized Therapies

Revision 22-3; Effective Oct. 25, 2022

Specialized therapy services must be related to the person’s disability. Specific therapeutic goals must be in place for each specialized therapy provided under the CLASS program to address the person’s disability. A current physician's order for each therapy is required before the delivery of specialized therapy services. Physician's orders are not necessary for an evaluation only.

The following activities may be billed under the CLASS program if included in the person's authorized IPC:

  • interacting in-person or by synchronous audio-visual technology with the person;
  • time spent by a therapist to train the person, LAR, primary caregiver or service provider in the proper use of an adaptive aid;
  • time spent teaching a service provider to reinforce therapy goals during ADL;
  • time spent by a therapist to perform face-to-face evaluations to determine a person’s need for skilled therapy service, adaptive aids or minor home modifications; and
  • participation on the SPT may be billed as a professional service, only:
    • when the person has an identified need for the service, and
    • for actual time spent in the capacity of the respective discipline.

The therapist must provide justification for time required to develop an assessment of the person’s need for and adaptive aid or minor home modification. The justification should include time necessary to conduct the assessment and research regarding the most appropriate and cost-effective manner to meet the person’s needs.

The following services are available under specialized therapies and may be billed under the CLASS program if included in the person’s authorized IPC.

  • Massage Therapy must be provided in-person by a licensed massage therapist.
  • Recreational Therapy must be provided by a certified therapeutic recreation specialist awarded by the National Council of Therapeutic Recreation Certification (NCTRC), or a therapeutic recreation specialist certified by the Consortium for Therapeutic Recreation/Activities Certification, Inc (CTRAC).
  • Music Therapy must be provided by a board-certified music therapist awarded by the Certification Board for Music Therapists.
  • Aquatic Therapy must be provided in-person by:
    • a licensed massage therapist;
    • a certified therapeutic recreation specialist awarded by the NCTRC;
    • a certified therapeutic recreation specialist awarded by the CTRAC; and
      • hold a certificate of completion of the "Basic Water Rescue" course from the American Red Cross; or
      • be certified by the American Red Cross as a lifeguard.
  • Hippotherapy must be provided in-person by:
    • a riding instructor certified by the Professional Association of Therapeutic Horsemanship International as a therapeutic riding instructor or by the North American Riding for the Handicapped Association; and
    • a licensed occupational therapist;
    • a licensed occupational therapy assistant;
    • a licensed physical therapist; or
    • a licensed physical therapist assistant.
  • Therapeutic Horseback Riding must be provided in-person by a riding instructor certified by the Professional Association of Therapeutic Horsemanship International or the North American Riding for the Handicapped Association as a therapeutic riding instructor.

Reimbursement Rates

The current specialized therapies unit rate ceiling per hour and requisition fees can be located on the HHSC Provider Finance website. For services with a unit rate ceiling, the rate negotiated with the provider agency must be at or below the approved ceiling rate; the negotiated rate then becomes the unit rate for that service.

7234 Cognitive Rehabilitation Therapy

Revision 15-2; Effective November 20, 2015

Cognitive Rehabilitation Therapy (CRT) assists an individual in learning or relearning cognitive skills that have been lost or altered, as a result of damage to brain cells or brain chemistry, in order to enable the individual to compensate for lost cognitive functions. CRT includes reinforcing, strengthening or reestablishing previously learned patterns of behavior, or establishing new patterns of cognitive activity or compensatory mechanisms for impaired neurological systems.

If an individual might need CRT, the assigned case manager must assist the individual in obtaining, in accordance with the Medicaid State Plan, a neurobehavioral or neuropsychological assessment and plan of care from a qualified professional as a non-CLASS program service.

A program provider must ensure a CRT service provider provides and monitors the provision of CRT to the individual in accordance with the plan of care and is a:

  • licensed psychologist;
  • licensed speech-language pathologist; or
  • licensed occupational therapist.

The plan of care for CRT is developed based on a neurobehavioral or neuropsychological assessment and plan of care from a qualified professional.

An acquired brain injury (ABI) is an injury to the brain that occurs after birth, is non-congenital and non-degenerative, and that disrupts the normal function of the brain. The definition of ABI also includes traumatic brain injury (TBI) and other brain injuries resulting from any anoxic condition. Additional information on acquired brain injuries is located on the website for the Texas Health and Human Services Commission office on Acquired Brain Injuries at https://www.hhs.texas.gov/services/disability/office-acquired-brain-injury.

7235 Dietary Services (Nutritional Services)

Revision 22-3; Effective Oct. 25, 2022

The provision of nutrition services is defined in Texas Occupations Code, Chapter 701. A program provider must ensure dietary services are provided by a licensed dietician.

The following activities may be billed under the CLASS program if included in the person’s authorized Individual Plan of Care:

  • assessing the nutritional needs of an individual and determining constraints and resources in the practice;
  • establishing priorities and goals that meet nutritional needs and are consistent with constraints and available resources;
  • providing counseling and educating an individual, family members, or other persons involved in the individual's care about nutrition in health and disease;
  • developing, implementing, and managing nutritional care systems or nutritional or dietary plans;
  • evaluating, changing and maintaining appropriate quality standards in food and nutritional care services;
  • training and consulting with an individual, family member, or other people involved in the individual's care regarding the implementation of a nutritional or dietary plan; or
  • time spent collaborating with the person or LAR, primary caregiver or service provider to transition the services to a non-therapist changing the role of the therapist to a supervisory role. 

7236 Auditory Integration/Auditory Enhancement Training

Revision 22-3; Effective Oct. 25, 2022

Auditory integration/auditory enhancement is specialized training that assists an individual to cope with hearing dysfunction or over-sensitivity to certain frequency ranges of sound by facilitating auditory processing skills and exercising the middle ear and auditory nervous system.

A program provider must ensure the service is provided by a licensed audiologist or a licensed assistant in audiology. An individual must have an audiogram performed in-person by a licensed audiologist as a pre-requisite for auditory integration/auditory enhancement training.

7240 Supported Employment, Prevocational Services and Employment Assistance

Revision 17-1; Effective November 1, 2017

Additional information regarding provision of supported employment, prevocational services, and employment assistance can be located in a guide available at hhs.texas.gov/services/disability/employment/employment-first/employment-guide-people-disabilities.

7241 Supported Employment

Revision 17-1; Effective November 1, 2017

Supported employment is a service that provides assistance to sustain competitive employment to an individual who requires intensive, ongoing support to be self-employed, work from home, or perform in a work setting at which individuals without disabilities are employed.

Competitive employment is employment that pays an individual at or above the greater of the applicable minimum wage or the prevailing wage paid to individuals without disabilities for performing the same or similar work.

A program provider must ensure a supported employment service provider:

  • is not the employer of the individual receiving the service or an employee of the individual's employer;
  • has a bachelor's degree or an associate's degree in rehabilitation, business, marketing or a related human services field with six months of paid or unpaid experience providing services to people with disabilities;
  • has a high school diploma or a certificate recognized by a state as the equivalent of a high school diploma, with two years of paid or unpaid experience providing services to people with disabilities;
  • does not perform supervisory activities rendered as a normal part of the business setting;
  • does not provide supports to an individual who does not require such supports to continue employment;
  • includes transportation necessary for the individual's participation in supported employment;
  • provides ongoing supervision and monitoring of the individual's satisfaction and performance on the job; and
  • does not provide supported employment to an individual with the individual present at the same time one of the following CLASS program services is provided:
    • CFC PAS/HAB;
    • transportation-habilitation;
    • respite;
    • prevocational;
    • nursing; and
    • employment assistance.

A service provider of supported employment may not be the:

  • parent of the individual if the individual is under 18 years of age; or
  • spouse of the individual.

Before including supported employment on an individual's IPC, a program provider must ensure similar services are not available to the individual through a program funded under Section 110 of the Rehabilitation Act of 1973 or the Individuals with Disabilities Education Act (20 USC 1401 et seq.). If an individual is already employed and in need of assistance maintaining a job, a CMA should not refer the individual to HHSC. Instead, the provider should seek approval through the individual's service plan to provide supported employment or other services needed to maintain an individual's employment.

HHSC does not authorize payment for training that is not directly related to an individual's supported employment program. The following activities may be billed to the CLASS program if included in the individual's authorized IPC:

  • face-to-face or telephone contact with an individual at the individual's work site to provide training, support and intervention necessary to sustain the individual's employment;
  • face-to-face or telephone contact with an individual's legally authorized representative to sustain the individual's employment;
  • face-to-face or telephone contact with an individual's employment supervisor as necessary to sustain the individual's employment;
  • participation in SPT meetings; and
  • transporting an individual to and from the work site.

7242 Prevocational Services

Revision 17-1; Effective November 1, 2017

Prevocational services are services that are not job-task oriented and are provided to an individual to prepare the individual for employment and who the SPT does not expect to be employed, without receiving supported employment, within one year after prevocational services begin.

Before including prevocational services on an individual's Individual Plan of Care (IPC), a program provider must ensure similar services are not available to the individual through a program funded under Section 110 of the Rehabilitation Act of 1973, or the Individuals with Disabilities Education Act (20 USC 1401 et seq). HHSC does not provide any services similar to CLASS prevocational services; therefore, a Case Management Agency (CMA) is not required to obtain a denial from HHSC before including prevocational services on an individual's IPC.

A program provider must ensure a provider of prevocational services:

  • has a bachelor's degree in a health and human services field, and two years work experience in the delivery of services and supports to persons with related conditions or similar disabilities; or
  • has one of the following:
    • a high school diploma and four years work experience in the delivery of services and supports to persons with related conditions or similar disabilities; or
    • a high school equivalency certificate issued in accordance with the law of the issuing state and four years work experience in the delivery of services and supports to persons with related conditions or similar disabilities.
  • does not provide prevocational services to the individual at the same time one of the following CLASS program services is provided:
  • CFC PAS/HAB;
  • transportation-habilitation;
  • respite;
  • prevocational;
  • nursing; and
  • employment assistance.

A service provider of prevocational services may not be the:

  • parent of the individual if the individual is under 18 years of age; or
  • spouse of the individual.

The following activities may be billed as prevocational services under the CLASS program if included in the individual's authorized IPC:

  • assessment of vocational skills an individual needs to develop or improve upon;
  • individual and group instruction regarding barriers to employment;
  • training in skills:
    • that are not job-task oriented;
    • that are related to goals identified in the individual's habilitation plan;
    • that are essential to obtaining and retaining employment, such as the effective use of community resources, transportation and mobility training; and
    • for which an individual is not compensated more than 50 percent of the federal minimum wage or industry standard, whichever is greater;
  • training in the use of adaptive equipment necessary to obtain and retain employment; and
  • transportation between the individual's place of residence and prevocational services site when other forms of transportation are unavailable or inaccessible.

7243 Employment Assistance

Revision 17-1; Effective November 1, 2017

Employment assistance is provided to an individual to help the individual locate competitive employment in the community.

A program provider must ensure an employment assistance service provider:

  • has a bachelor's degree or an associate's degree in rehabilitation, business, marketing or a related human services field with six months of paid or unpaid experience providing services to people with disabilities;
  • has a high school diploma or a certificate recognized by a state as the equivalent of a high school diploma, with two years of paid or unpaid experience providing services to people with disabilities;
  • does not provide employment assistance to an individual with the individual present at the same time one of the following CLASS program services is provided:
    • CFC PAS/HAB;
    • transportation-habilitation;
    • respite;
    • prevocational;
    • nursing; and
    • employment assistance.

A service provider of employment assistance may not be the:

  • parent of the individual if the individual is under 18 years of age; or
  • spouse of the individual.

Before including employment assistance on an individual's Individual Plan of Care (IPC), a program provider must ensure similar services are not available to the individual through a program funded under Section 110 of the Rehabilitation Act of 1973 or the Individuals with Disabilities Education Act (20 USC 1401 et seq.).

An individual seeking employment assistance must apply for those services through HHSC before receiving employment assistance services through CLASS services. CLASS may provide employment assistance to individuals who have applied for services through HHSC until HHSC completes development of the individual plan for employment (IPE).

HHSC does not authorize payment for training that is not directly related to an individual's employment assistance program. The following activities may be billed to the CLASS program if included in the individual's authorized IPC:

  • identifying an individual's employment preferences, job skills, and requirements for a work setting and work conditions;
  • locating prospective employers offering employment compatible with an individual's identified preferences, skills and requirements;
  • contacting a prospective employer on behalf of an individual and negotiating the individual's employment;
  • transporting the individual to help the individual locate competitive employment in the community; and
  • participating in SPT meetings.

7250 Transition Assistance Services (TAS)

Revision 15-2; Effective November 20, 2015

TAS assists an individual in setting up a household in the community before being discharged from a nursing facility or an intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID) and enrolling in the CLASS program. There is a cost limit of $2,500 for TAS and an individual may receive TAS only once in the individual's lifetime. TAS is not available if an individual's enrollment IPC includes support family services or continued family services in the CLASS program.

Available services include:

  • payment of security deposits required to lease a home, including an apartment, or to establish utility services for a home;
  • the purchase of essential furnishings for a home, including a table, bed, chairs, window blinds, eating utensils and food preparation items;
  • payment of expenses required to move personal items, including furniture and clothing, into a home;
  • payment for services to ensure the health and safety of the individual in a home, including pest eradication, allergen control or a one-time cleaning before occupancy; and
  • the purchase of essential supplies for a home, including toilet paper, towels and bed linens. For more details, see 40 Texas Administrative Code, Part 1, Chapter 62, Transition Assistance Services.

7260 Support Family Services (SFS) and Continued Family Services (CFS)

Revision 11-1; Effective June 13, 2011

7261 SFS

Revision 17-1; Effective November 1, 2017

SFS consist of services required for an individual under age 18 in the CLASS program to reside within the home of a family other than the home of the natural or adopted parent(s). The support family agency will recruit, train and certify the SFS provider. The SPT, including the support family agency, will coordinate placement into an SFS provider.

The support family agency must be licensed by the Department of Family and Protective Services (DFPS) as a child placing agency and maintain a current Medicaid provider agreement with HHSC to provide SFS.

SFS is reimbursed at a daily rate to provide 24-hour services that include:

  • direct personal assistance with an ADL (e.g., grooming, eating, bathing, dressing and personal hygiene);
  • assistance with meal planning and preparation;
  • assistance with securing and providing transportation;
  • assistance with housekeeping;
  • assistance with ambulation and mobility;
  • reinforcement of counseling, therapy and educational activities;
  • assistance with medications and the performance of tasks delegated by an RN;
  • supervision of the individual's safety and security;
  • facilitating inclusion in community activities, by the use of natural supports, social interaction, participation in leisure activities and development of socially valued behaviors; and
  • services that train the individual to acquire, retain, and improve self-help, socialization, and daily living skills or assisting the individual with ADLs.

7262 CFS

Revision 17-1; Effective November 1, 2017

CFS is for people who are unable to continue with SFS. CFS provides a 24-hour family living arrangement in a home using the same criteria for SFS and meeting the requirements of a support family home. The continued family agency will recruit, train and certify the CFS provider. The case manager, the continued family agency, the natural family and the DSA will coordinate placements into a CFS provider.

A continued family agency must be licensed by DFPS as a child placing agency and maintain a current Medicaid provider agreement with HHSC to provide CFS.

CFS is reimbursed at a daily rate to provide 24-hour services that include:

  • direct personal assistance with an ADL (e.g., grooming, eating, bathing, dressing and personal hygiene);
  • assistance with meal planning and preparation;
  • assistance with securing and providing transportation;
  • assistance with housekeeping;
  • assistance with ambulation and mobility;
  • reinforcement of counseling, therapy and educational activities;
  • assistance with medications and the performance of tasks delegated by a registered nurse;
  • supervision of the individual's safety and security;
  • facilitating inclusion in community activities by the use of natural supports, social interaction, participation in leisure activities and development of socially valued behaviors; and
  • services that train the individual to acquire, retain, and improve self-help, socialization, and daily living skills or assisting the individual with ADLs.

7270 Adaptive Aids, Minor Home Modifications and Dental Treatment

Revision 17-1; Effective November 1, 2017

7271 Adaptive Aids

Revision 20-2; Effective March 11, 2020

An adaptive aid is an item or service that enables an individual to retain or increase the ability to perform ADL or perceive, control or communicate with the environment in which the individual lives.

The maximum allowable for adaptive aids and dental treatment combined is $10,000 per IPC period for an adaptive aid listed in Appendix I, Adaptive Aids.

The following may be billed under the CLASS program if included in the individual's authorized IPC:

  • actual cost of the adaptive aid;
  • repair and maintenance of an adaptive aid not covered by warranty;
  • the cost of a specification for the adaptive aid;
  • the cost of an independent inspection performed by a certified automotive technician on a vehicle that is expected to be modified or adapted, according to Appendix I. The cost of this inspection must not exceed $150; and
  • rental of equipment, not to exceed 90 days, to:
    • evaluate the benefit on a trial basis for a short period of time; or
    • allow for the repair, purchase or replacement of essential adaptive aids.

7272 Minor Home Modifications

Revision 12-1; Effective January 13, 2012

A minor home modification is a physical adaptation to an individual's residence is necessary to address the individual's specific needs and enables the individual to function with greater independence in the individual's residence or to control his or her environment.

The maximum allowable for minor home modifications is $10,000 for the lifetime of the individual and up to $300 per IPC period for repair and maintenance of minor home modifications purchased through the CLASS program after the lifetime cost limit has been met.

The following may be billed under the CLASS program if included in the individual's authorized IPC:

  • actual cost of the minor home modification, including installation;
  • repair and maintenance of a minor home modification not covered by warranty after one year has passed from the date the minor home modification was completed;
  • the cost of a specification for the minor home modification; and
  • the cost of an inspection of the minor home modification.

If the minor home modification has several components, these may be billed separately as they are completed (e.g., bathroom modification that involves widening a doorway, adding grab bars to the tub and installing a special toilet adaptation). Materials may be billed separately from the labor necessary to complete the task.

7273 Dental Treatment

Revision 17-1; Effective November 1, 2017

The following routine preventive, therapeutic, orthodontic and emergency dental treatment may be billed under the CLASS program if included in the individual's authorized IPC:

  • procedures necessary to control bleeding, relieve pain and eliminate acute infection;
  • operative procedures required to prevent the imminent loss of teeth;
  • treatment of injuries to the teeth or supporting structures;
  • examinations;
  • x-rays;
  • cleanings;
  • sealants;
  • oral prophylaxes;
  • topical fluoride treatment;
  • fillings;
  • scaling;
  • extractions;
  • crowns;
  • pulp therapy;
  • restoration of caries (cavities);
  • maintenance of space;
  • limited provision of removable prostheses when masticatory function is impaired, when an existing prosthesis is un-servable, or when aesthetic consideration interfere with employment or social development;
  • treatment of retained deciduous teeth;
  • treatment of cross-bite therapy;
  • treatment of facial accidents involving severe traumatic deviations;
  • treatment of cleft palates with gross malocclusion;
  • treatment of handicapping malocclusions affecting permanent dentition with a minimum score of 26 as measured on the Handicapping Labio-lingual Deviation Index; and
  • sedation necessary to perform dental treatment including non-routine anesthesia (e.g., intravenous sedation, general anesthesia or sedative therapy prior to routine procedures).

Cosmetic orthodontia is excluded from CLASS program services.

7280 Transportation-Habilitation, CFC PAS/HAB and Respite Care

Revision 17-1; Effective November 1, 2017

7281 Transportation - Habilitation

Revision 17-1; Effective November 1, 2017

A program provider must ensure a transportation-habilitation service provider who is hired on or after July 1, 2015, has:

  • a high school diploma or a certificate recognized by a state as the equivalent of a high school diploma; or
  • both of the following:
    • a successfully completed written competency-based assessment demonstrating the service provider's ability to perform habilitation, including an ability to perform habilitation tasks required for the individual to whom the service provider will provide habilitation; and
    • at least three written personal references from persons who are not relatives of the service provider that evidence the service provider's ability to provide a safe and healthy environment for the individual.

The following activities may be billed to the CLASS program if included in the individual's authorized IPC:

  • time spent in direct contact with the individual that includes time spent by the habilitation service provider delivering transportation services according to the Individual Program Plan (IPP), Individual Program Plan Addendum (IPP-A), IPC and habilitation plan or transportation plan;
  • time spent participating on the SPT as the appropriate DSA representative, if the person attending meets the qualifications as the official representative of the DSA;
  • time spent operating a vehicle while transporting an individual according to the IPP, IPP-A and Transportation Plan.

7281.1 Community First Choice (CFC) Personal Assistance Services/Habilitation (PAS/HAB)

Revision 17-1; Effective November 1, 2017

Effective June 1, 2015, the majority of activities previously included as part of the CLASS habilitation services are now available through the non-waiver Medicaid state plan CFC PAS/HAB service.

A program provider must ensure a CFC PAS/HAB service provider has:

  • a high school diploma or a certificate recognized by a state as the equivalent of a high school diploma; or
  • both of the following:
    • a successfully completed written competency-based assessment demonstrating the service provider's ability to perform habilitation, including an ability to perform habilitation tasks required for the individual to whom the service provider will provide habilitation; and
    • at least three written personal references from persons who are not relatives of the service provider that evidence the service provider's ability to provide a safe and healthy environment for the individual.

The following activities may be billed to CFC PAS/HAB if included in the individual's authorized IPC:

  • personal assistance services that provide assistance to an individual in performing ADLs and IADLs based on the individual's person-centered service plan, including:
  • non-skilled assistance with the performance of the ADLs and IADLs;
  • household chores necessary to maintain the home in a clean, sanitary, and safe environment;
  • escort services, which consist of accompanying and assisting an individual to access services or activities in the community, but do not include operating a vehicle while transporting an individual; and
  • assistance with health-related tasks; and
  • habilitation that provides assistance to an individual in acquiring, retaining and improving self-help, socialization and daily living skills and training the individual on ADLs, IADLs and health-related tasks, such as:
    • self-care;
    • personal hygiene;
    • household tasks;
    • mobility;
    • money management;
    • community integration, including how to get around in the community;
    • use of adaptive equipment;
    • personal decision making;
    • reduction of challenging behaviors to allow individuals to accomplish ADLs, IADLs, and health-related tasks; and
    • self-administration of medication.

7281.2 Community First Choice (CFC) Support Management

Revision 17-1; Effective November 1, 2017

CFC support management offers training on how to select, manage, and dismiss an unlicensed service provider of CFC PAS/HAB. There is no reimbursement rate for CFC Support Management. CFC Support Management is available to all individuals and is different from CDS Support Consultation as described in Section 4100. A Financial Management Services Agency (FMSA) are required to offer support management.

7282 Respite Care

Revision 17-1; Effective November 1, 2017

An individual is eligible for respite if:

  • the person who routinely provides assistance and support and resides with the individual is temporarily unavailable to provide the routine assistance and support;
  • the amount of respite does not exceed the amount of unpaid assistance and support routinely provided by the person who routinely provides this assistance and support;
  • the service provider of respite or employee in the CDS option of respite does not reside with the individual; and
  • the individual does not receive support family services or continued family services at the same time as respite is being provided;
  • respite is reimbursed at a daily rate to provide the following services for 24 hours;
  • interacting face-to-face with an individual who is awake to assist the individual in the following activities;
    • self-care;
    • personal hygiene;
    • ambulation and mobility;
    • money management;
    • community integration;
    • use of adaptive equipment;
    • self-administration of medication;
    • reinforce any therapeutic goal of the individual;
    • provide transportation to the individual; and
    • protect the individual's health, safety and security;
  • interacting face-to-face or by telephone with an individual or an involved person regarding an incident that directly affects the individual's health or safety; and
  • performing one of the following activities that does not involve interacting face-to-face with an individual:
    • shopping for the individual;
    • planning or preparing meals for the individual;
    • housekeeping for the individual;
    • procuring or preparing the individual's medication;
    • arranging transportation for the individual; or
    • protecting the individual's health, safety and security while the individual is asleep.

Because respite includes personal care, the provider may not bill for habilitation when the individual is in the respite setting. The provider may bill for other CLASS program services the individual requires while in the respite setting. The provider may not bill for minor home modifications made to an out-of-home respite setting.

7290 Pre-Enrollment Assessments

Revision 17-1; Effective November 1, 2017

The CMA is reimbursed a pre-enrollment assessment fee for providing case management services necessary to enroll an applicant into the CLASS program. The pre-enrollment assessment fee reimburses costs prior to the date the applicant is determined to be eligible for CLASS services.

For a full assessment fee, the case manager must submit a completed Form 3621, CLASS/CFC – Individual Plan of Care, along with a completed Form 3625, CLASS/CFC – Documentation of Services Delivered.

A partial assessment fee may be requested in the event the applicant declines CLASS program services or does not meet eligibility requirements. For a partial assessment fee, the case manager must submit a completed Form 3657, Pre-Enrollment Assessment, which should be submitted with completed Form 3625 to HHSC.

The DSA is reimbursed a pre-enrollment assessment fee for providing pre-enrollment activities necessary to enroll an applicant into the CLASS program as outlined in Section 3310, Enrollment. The pre-enrollment assessment fee reimburses costs prior to the date the applicant is determined to be eligible for CLASS services.

7300, Non-Billable Time and Activities

Revision 17-1; Effective November 1, 2017

The following are examples of non-billable time and activities:

  • phone calls, letters or meetings with HHSC or non-CLASS resources when the activity does not benefit a specific individual;
  • administrative meetings or staff meetings;
  • in-service training, continuing education or conferences;
  • employee conferences or evaluations;
  • filing claims for services;
  • traveling to and from the individual's home, unless the service provider is accompanied by the individual receiving services;
  • travel time spent by the DSA staff to obtain, purchase or deliver an adaptive aid;
  • processing paperwork;
  • minor home modifications not listed in Appendix II, Minor Home Modification Services, as available items;
  • adaptive aids not listed in Appendix I, Adaptive Aids, as available items;
  • adaptive aids or medical supplies offered as pre-owned, used or refurbished;
  • collateral contact when that contact is between a program provider's service providers;
  • "down-time" such as illness, holidays or vacation time;
  • contact with the individual or LAR while admitted to an institutional setting (hospital, nursing facility, rehabilitation hospital, intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID), state supported living center or state hospital);
  • collateral contact (telephone or face to face) to assist or discuss a specific individual services (e.g., helping access non-CLASS resources);
  • leaving a phone message on a recorder or leaving a message with anyone other than the individual or LAR;
  • direct contact with the individual or LAR by a DSA representative when contact is about coordination of service providers or finding replacement service providers — the cost associated with this time is an allowable cost and should be reported in the DSA's cost report;
  • mediation/problem-solving performed by a DSA representative between the CLASS service provider and the individual — the cost associated with this time should be reported in the DSA's cost report; and
  • time spent by a DSA representative to train a direct service provider.

7400, Duplicate Services

Revision 17-1; Effective November 1, 2017

A direct service provider may bill for only one service at a time. Examples include:

  • A transportation-habilitation service provider transports an individual to community services for one hour while discussing life skill training with the individual. The provider may only bill for one unit of habilitation, not two.
  • A CFC PAS/HAB service provider spends one hour cooking a meal while teaching the individual to cook at the same time. The provider agency may bill for only one unit of habilitation, not two.
  • An individual who is receiving CFC PAS/HAB services may not simultaneously receive respite services.

7500, Billable Units

Revision 17-1; Effective November 1, 2017

A billable unit of service is the method for calculating the amount the provider agency may bill HHSC. Units are measured by increments of time or by the cost of the item provided.

7510 Services Unit Measurements

Revision 17-1; Effective November 1, 2017

The following services use time as the measure. One unit of service is defined as:

Case Management Monthly Rate
Transportation-Habilitation one hour
CFC PAS/HAB one hour
Nursing one hour
Occupational Therapy one hour
Physical Therapy one hour
Speech and Language Pathology one hour
Cognitive Rehabilitation Therapy one hour
Behavioral Support Services one hour
Dietary Services one hour
Respite one 24-hour period
Specialized Therapies one hour
Supported Employment one hour
Employment Assistance one hour
Prevocational Services one hour
Support Family Services daily rate
Continued family services daily rate

The following services are measured by the cost of the item provided:

  • adaptive aids
  • minor home modifications
  • dental services
  • TAS

All services measured by the hour use the following formula to calculate the billable unit, unless the service is respite.

Number of providers × time spent delivering services ÷ number of individuals served = billable unit of services
Examples:
1 provider × 1 hour of service ÷ 1 individual = 1 billable hour
1 provider × 1 hour of service ÷ 2 individuals = 1/2 hour billable per individual
1 provider × 1 hour of service ÷ 3 individuals = 1/3 hour billable per individual
2 providers × 1 hour of service ÷ 3 individuals = 2/3 hour billable per individual

7520 Respite Care

Revision 11-1; Effective June 13, 2011

The unit of service for respite care is defined as a 24-hour period. The respite rate is billed for each individual in a respite setting.

Examples

  • One individual in a respite setting for 24 hours = 1 billable unit
  • Two individuals in a respite setting for 24 hours = 1 billable unit per individual
  • Three individuals in a respite setting for 24 hours = 1 billable unit per individual

7600, Determining Billable Units for an Hourly Service

evision 20-4; Effective October 9, 2020

For a service that has a billable unit of one hour, a provider agency must determine the billable units using the amount of time that a service provider spent providing the service in accordance with the table below.

Service TimeBillable Unit(s) of Service
Less than 8 minutes0.00
At least 8 minutes, but less than 23 minutes0.25
At least 23 minutes, but less than 38 minutes0.50
At least 38 minutes, but less than 53 minutes0.75
At least 53 minutes, but less than 1 hour 8 minutes1.00
At least 1 hour 8 minutes, but less than 1 hour 23 minutes1.25
At least 1 hour 23 minutes, but less than 1 hour 38 minutes1.50
At least 1 hour 38 minutes, but less than 1 hour 53 minutes1.75
At least 1 hour 53 minutes, but less than 2 hours 8 minutes2.00
At least 2 hours 8 minutes, but less than 2 hours 23 minutes2.25
At least 2 hours 23 minutes, but less than 2 hours 38 minutes2.50
At least 2 hours 38 minutes, but less than 2 hours 53 minutes2.75
At least 2 hours 53 minutes, but less than 3 hours 8 minutes3.00
At least 3 hours 8 minutes, but less than 3 hours 23 minutes3.25
At least 3 hours 23 minutes, but less than 3 hours 38 minutes3.50
At least 3 hours 38 minutes, but less than 3 hours 53 minutes3.75
At least 3 hours 53 minutes, but less than 4 hours 8 minutes4.00
At least 4 hours 8 minutes, but less than 4 hours 23 minutes4.25
At least 4 hours 23 minutes, but less than 4 hours 38 minutes4.50
At least 4 hours 38 minutes, but less than 4 hours 53 minutes4.75
At least 4 hours 53 minutes, but less than 5 hours 8 minutes5.00
At least 5 hours 8 minutes, but less than 5 hours 23 minutes5.25
At least 5 hours 23 minutes, but less than 5 hours 38 minutes5.50
At least 5 hours 38 minutes, but less than 5 hours 53 minutes5.75
At least 5 hours 53 minutes, but less than 6 hours 8 minutes6.00
At least 6 hours 8 minutes, but less than 6 hours 23 minutes6.25
At least 6 hours 23 minutes, but less than 6 hours 38 minutes6.50
At least 6 hours 38 minutes, but less than 6 hours 53 minutes6.75
At least 6 hours 53 minutes, but less than 7 hours 8 minutes7.00
At least 7 hours 8 minutes, but less than 7 hours 23 minutes7.25
At least 7 hours 23 minutes, but less than 7 hours 38 minutes7.50
At least 7 hours 38 minutes, but less than 7 hours 53 minutes7.75
At least 7 hours 53 minutes, but less than 8 hours 8 minutes8.00
At least 8 hours 8 minutes, but less than 8 hours 23 minutes8.25
At least 8 hours 23 minutes, but less than 8 hours 38 minutes8.50
At least 8 hours 38 minutes, but less than 8 hours 53 minutes8.75
At least 8 hours 53 minutes, but less than 9 hours 8 minutes9.00
At least 9 hours 8 minutes, but less than 9 hours 23 minutes9.25
At least 9 hours 23 minutes, but less than 9 hours 38 minutes9.50
At least 9 hours 38 minutes, but less than 9 hours 53 minutes9.75
At least 9 hours 53 minutes, but less than 10 hours 8 minutes10.00
At least 10 hours 8 minutes, but less than 10 hours 23 minutes10.25
At least 10 hours 23 minutes, but less than 10 hours 38 minutes10.50
At least 10 hours 38 minutes, but less than 10 hours 53 minutes10.75
At least 10 hours 53 minutes, but less than 11 hours 8 minutes11.00
At least 11 hours 8 minutes, but less than 11 hours 23 minutes11.25
At least 11 hours 23 minutes, but less than 11 hours 38 minutes11.50
At least 11 hours 38 minutes, but less than 11 hours 53 minutes11.75
At least 11 hours 53 minutes, but less than 12 hours 8 minutes12.00
At least 12 hours 8 minutes, but less than 12 hours 23 minutes12.25
At least 12 hours 23 minutes, but less than 12 hours 38 minutes12.50
At least 12 hours 38 minutes, but less than 12 hours 53 minutes12.75
At least 12 hours 53 minutes, but less than 13 hours 8 minutes13.00
At least 13 hours 8 minutes, but less than 13 hours 23 minutes13.25
At least 13 hours 23 minutes, but less than 13 hours 38 minutes13.50
At least 13 hours 38 minutes, but less than 13 hours 53 minutes13.75
At least 13 hours 53 minutes, but less than 14 hours 8 minutes14.00
At least 14 hours 8 minutes, but less than 14 hours 23 minutes14.25
At least 14 hours 23 minutes, but less than 14 hours 38 minutes14.50
At least 14 hours 38 minutes, but less than 14 hours 53 minutes14.75
At least 14 hours 53 minutes, but less than 15 hours 8 minutes15.00
At least 15 hours 8 minutes, but less than 15 hours 23 minutes15.25
At least 15 hours 23 minutes, but less than 15 hours 38 minutes15.50
At least 15 hours 38 minutes, but less than 15 hours 53 minutes15.75
At least 15 hours 53 minutes, but less than 16 hours 8 minutes16.00
At least 16 hours 8 minutes, but less than 16 hours 23 minutes16.25
At least 16 hours 23 minutes, but less than 16 hours 38 minutes16.50
At least 16 hours 38 minutes, but less than 16 hours 53 minutes16.75
At least 16 hours 53 minutes, but less than 17 hours 8 minutes17.00
At least 17 hours 8 minutes, but less than 17 hours 23 minutes17.25
At least 17 hours 23 minutes, but less than 17 hours 38 minutes17.50
At least 17 hours 38 minutes, but less than 17 hours 53 minutes17.75
At least 17 hours 53 minutes, but less than 18 hours 8 minutes18.00
At least 18 hours 8 minutes, but less than 18 hours 23 minutes18.25
At least 18 hours 23 minutes, but less than 18 hours 38 minutes18.50
At least 18 hours 38 minutes, but less than 18 hours 53 minutes18.75
At least 18 hours 53 minutes, but less than 19 hours 8 minutes19.00
At least 19 hours 8 minutes, but less than 19 hours 23 minutes19.25
At least 19 hours 23 minutes, but less than 19 hours 38 minutes19.50
At least 19 hours 38 minutes, but less than 19 hours 53 minutes19.75
At least 19 hours 53 minutes, but less than 20 hours 8 minutes20.00
At least 20 hours 8 minutes, but less than 20 hours 23 minutes20.25
At least 20 hours 23 minutes, but less than 20 hours 38 minutes20.50
At least 20 hours 38 minutes, but less than 20 hours 53 minutes20.75
At least 20 hours 53 minutes, but less than 21 hours 8 minutes21.00
At least 21 hours 8 minutes, but less than 21 hours 23 minutes21.25
At least 21 hours 23 minutes, but less than 21 hours 38 minutes21.50
At least 21 hours 38 minutes, but less than 21 hours 53 minutes21.75
At least 21 hours 53 minutes, but less than 22 hours 8 minutes22.00
At least 22 hours 8 minutes, but less than 22 hours 23 minutes22.25
At least 22 hours 23 minutes, but less than 22 hours 38 minutes22.50
At least 22 hours 38 minutes, but less than 22 hours 53 minutes22.75
At least 22 hours 53 minutes, but less than 23 hours 8 minutes23.00
At least 23 hours 8 minutes, but less than 23 hours 23 minutes23.25
At least 23 hours 23 minutes, but less than 23 hours 38 minutes23.50
At least 23 hours 38 minutes, but less than 23 hours 53 minutes23.75
At least 23 hours 53 minutes, but less than 24 hours 8 minutes24.00

7601 Determining Billable Units for Multiple Service Events

Revision 20-4; Effective October 9, 2020

For a service with a billable unit of one hour, if there is more than one service event of the same service in a calendar month, a program provider must determine total billable units for the month by determining the billable units for each service event and adding the billable units together.

Example:

Service ProviderTime Service BeginsTime Service EndsDuration of Service EventBillable Units
Service Provider A8:00 a.m.4:05 p.m.8 hours 5 minutes8.00
Service Provider B4:45 p.m.6:07 p.m.1 hour 22 minutes1.25
Service Provider B8:50 p.m.11:01 p.m.2 hours 11 minutes2.25
Total Billable Units11.50

7610 Billing Units of Respite Service

Revision 11-1; Effective June 13, 2011

Partial units of respite are calculated as follows:

Service TimeUnit of Service
1 hour of service= 1/24 unit (.04)
2 hours of service= 2/24 unit (.08)
3 hours of service= 3/24 unit (.12)
4 hours of service= 4/24 unit (.17)
5 hours of service= 5/24 unit (.21)
6 hours of service= 6/24 unit (.25)
7 hours of service= 7/24 unit (.29)
8 hours of service= 8/24 unit (.33)
9 hours of service= 9/24 unit (.37)
10 hours of service= 10/24 unit (.42)
11 hours of service= 11/24 unit (.46)
12 hours of service= 12/24 unit (.50)
13 hours of service= 13/24 unit (.54)
14 hours of service= 14/24 unit (.58)
15 hours of service= 15/24 unit (.62)
16 hours of service= 16/24 unit (.67)
17 hours of service= 17/24 unit (.71)
18 hours of service= 18/24 unit (.75)
19 hours of service= 19/24 unit (.79)
20 hours of service= 20/24 unit (.83)
21 hours of service= 21/24 unit (.87)
22 hours of service= 22/24 unit (.92)
23 hours of service= 23/24 unit (.96)
24 hours of service= 24/24 unit (1.0)

7620 Billing Units of Out-of-Home Respite Service

Revision 11-1; Effective June 13, 2011

The DSA must use the following procedure to bill as closely as possible to the actual cost for out-of-home respite services delivered. To calculate the units of respite that the DSA would bill for, the provider needs to calculate to the nearest partial unit the amount that allows adequate reimbursement to cover the actual cost of the service based on the current out-of-home respite rate per 24-hour period. This is done by dividing the total actual cost for respite by the current daily rate.

Administrative costs to the DSA related to arranging for respite services cannot be included in this billing calculation but should be reported on the DSA's cost report.

7700, Record Keeping Requirements

Revision 11-1; Effective June 13, 2011

The provider agency must maintain financial and supporting documents, statistical records and any other records pertinent to the services for which a claim or cost report was submitted to the department or its agent. If a provider agreement or contract has no specific termination date in effect, the records and documents must be kept for a minimum of three years and 90 days after the end of the federal fiscal year in which services were provided. If any litigation, claim or audit involving these records begins before the three-year period expires, the provider agency must keep the records and documents for at least three years and 90 days or until all litigation, claims or audit findings are resolved. The case is considered resolved when a final order is issued in litigation or the department and provider agency enter into a written agreement. The provider agency must keep records of non-expendable property acquired under the contract for three years after the final disposition of the property. In this section, contract period means the begin date through the end date specified in the original contract; extensions are considered separate contract periods.

The provider agency must maintain medical records for five years from the date the last services were delivered to the individual by the provider agency.

Medical records include:

  • Form 8578, Intellectual Disability/Related Condition Assessment;
  • assessments and evaluations containing individual medical information;
  • any other records containing individual medical information;
  • physician orders; and
  • Individual Plan of Care/Individual Program Plan.

7800, Service Delivery Records

Revision 17-1; Effective November 1, 2017

The CMA will maintain individual records that contain information required by HHSC and CLASS for a period of six years. Documentation must be maintained in each individual's record to include:

  • identifying information — name, sex, race, date of enrollment, citizenship, residence, marital status, Social Security number, Medicaid number;
  • name, address and phone number of responsible or interested parties;
  • financial information (income);
  • incident reports;
  • if the individual requires supported employment services and is not already employed, written verification of HHSC determination of eligibility or denial of supported employment services;
  • if the individual requires employment assistance services, written verification of the HHSC determination of eligibility or denial of supported employment services unless CLASS employment assistance services are being provided while awaiting HHSC to develop an individual plan for employment (IPE) for the individual;
  • case management activities to include the:
    • date of contact;
    • description of the case management provided;
    • progress or lack of progress in achieving goals or outcomes in observable, measurable terms that directly relate to the specific goal or objective addressed;
    • person with whom the contact occurred; and
    • case manager who provided the contact.
  • if the individual is in school, the individual education plan (IEP) for the individual;
  • discharge summaries; and
  • additional required documentation:
    • individual's current IPC;
    • individual's current person-centered plan, IPP-A
    • individual's current IPP;
    • individual's current Intellectual Disability/Related Condition (ID/RC) Assessment; and
    • any other relevant documentation concerning the individual.

The DSA will maintain individual records that contain information required by HHSC and CLASS for a period of six years. Documentation must be maintained in each individual's record to include:

  • identifying information — name, sex, race, date of enrollment, citizenship, residence, marital status, Social Security number, Medicaid number;
  • name, address and phone number of responsible or interested parties;
  • physicians' orders for medications and treatments, and any other medical records;
  • consent statements for money management;
  • evaluations of progress towards individual goals to include the:
    • type of CLASS program service provided;
    • date and the time the service begins and ends;
    • type of contact (phone or face-to-face);
    • name of the person with whom the contact occurred;
    • description of the activities performed, unless the activity performed is a non-delegated task that is provided by an unlicensed service provider and is documented on the IPP; and
    • signature and title of the service provider;
  • incident reports;
  • trust fund records;
  • documentation that employment assistance or supported employment is not available to the individual under a program funded under §110 of the Rehabilitation Act of 1973 or under a program funded under the Individuals with Disabilities Education Act (20 U.S.C. §1401 et seq.); and
  • these forms, as identified in Title 40 of the TAC §45.807:
    • a copy of the individual's current IPC;
    • a copy of the individual's current IPP-A;
    • a copy of the individual's current IPP;
    • a copy of the individual's current ID/RC Assessment;
    • a copy of the current adaptive behavior screening assessment;
    • a copy of the current HHSC CLASS/DBMD Nursing Assessment form
    • a copy of the current Related Conditions Eligibility Screening Instrument;
    • any new or revised Form 3628, Provider Agency Model Service Backup Plan, for the current IPC period; and
    • any other relevant documentation concerning the individual.

Evidence that employment assistance is not available to the individual under a program funded under §110 of the Rehabilitation Act of 1973 or under a program funded under the Individuals with Disabilities Education Act, must include documentation of the individual having applied for HHSC. Individuals receiving educational services through a school system must seek to have employment assistance or supported employment services included in the Individual Education Plan, when appropriate.

The requirement to document the service provided in an individual's record does not apply if the service/activity performed is a non-delegated task provided by an unlicensed service provider that is documented on the IPP.

Appendix I, Adaptive Aids

Revision 20-2; Effective March 11, 2020

Adaptive aids are items or services necessary to assist an individual to maintain function or to treat, rehabilitate, prevent or compensate for conditions resulting in disability or loss of function. Adaptive aids enable individuals with functional impairments to perform activities of daily living or to control the environment in which they live. Adaptive aids purchased through the Community Living Assistance and Support Services (CLASS) program are essential items or services provided to enhance the individual's independence in the community. For some individuals, adaptive aids are basic to making the environment usable so activities such as preparing food, eating, dispensing medications, dressing and grooming, maintaining the home, and moving within the community, can be performed as independently as possible. Adaptive aids are devices, controls, appliances or services that enable individuals with related conditions to:

  • increase their abilities to perform activities of daily living and decrease the need for paid staff;
  • prevent the risk of institutionalization;
  • control the environment in which they live;
  • modify or improve the individual's ability to live successfully in the community;
  • increase the individual's safety, security and accessibility; and
  • improve service accessibility and delivery.

Adaptive aids may be provided to meet the needs identified in an assessment conducted by an appropriate, licensed professional, as outlined in this appendix. The long-range cost effectiveness of adaptive aids will be considered since these items often provide several years of service.

Limits on the amount, frequency, or duration of this service:

Nutritional supplements and enteral feeding formulas and supplies available through the CLASS program are limited to those listed on the website maintained by Noridian Healthcare Solutions at: https://www.dmepdac.com/dmecsapp/

To determine if the requested nutritional supplement might be available through the CLASS program, navigate to the Noridian Healthcare Solutions website. On that Web page, in the section labeled “Search DMEPOS Product Classification List,” enter the product name in the text box labeled “Product Name,” and click the “GO” button. If the product is displayed on the resulting page, the nutritional supplements may be reimbursed by the CLASS program, based on the justification provided.

The same website can also provide a list of all nutritional supplements. Navigate to the same website listed above and in the section labeled “Search DMEPOS Product Classification List,” locate the text at box labeled “Classification.” Highlight the category “Enteral Nutrition” and click the “GO” button. This will provide a list of all nutritional products that may be reimbursable through the CLASS program.

Adaptive Aids are provided under this waiver when no other financial resource is available or when other available resources have been exhausted.

Form 3660, Request for Adaptive Aids, Medical Supplies, Minor Home Modifications or Dental Services/Sedation, is required for all requested adaptive aids. Requests for adaptive aids that require additional information to be provided by the appropriate licensed professional (as listed below) or require bids must accompany Form 3660, as applicable.

If the requested adaptive aid is related to transportation services, the case manager must complete Form 3598, Individual Transportation Plan, based on the deliberations of the service planning team (SPT). This form must be submitted to the Texas Health and Human Services Commission (HHSC) in conjunction with applicable forms as outlined below.

All assessments for adaptive aids requested through the CLASS program must:

  • be based on a face-to-face evaluation of the individual by the appropriate licensed professional, practicing within the scope of his/her licensure, conducted not more than one year before the date of purchase of the adaptive aid;
  • include a description of and a recommendation for a specific adaptive aid listed in this appendix and any associated items or modifications necessary to make the adaptive aid functional;
  • include the individual's diagnosis of a related condition(s) and identify how this adaptive aid will meet the needs of the individual and must include consideration of alternatives known to the appropriate licensed professional to meet the individual’s need(s) based on this diagnosis (for example, cerebral palsy, quadriplegia or deafness);
  • include a description of the symptom(s) related to the diagnosis (for example, unable to ambulate without assistance); and
  • include a description of the specific needs of the individual and how the adaptive aid will meet those needs (for example, the individual needs to ambulate safely and independently from room to room and the use of a walker will allow him to do so).

Adaptive aids needed on an ongoing basis will require documentation to justify the need for the adaptive aid(s) once per Individual Plan of Care (IPC) period. Repair and maintenance of items purchased through the CLASS program do not require justification unless the cost of the repair is expected to exceed $300.

However, the repair does require justification from a licensed professional if the cost exceeds $300 or the repair is to an adaptive aid not purchased through CLASS.

The maximum amount HHSC will authorize as payment to a direct services agency (DSA) for all adaptive aids and dental treatment combined for an individual is $10,000 per IPC period, which includes the cost of repair and maintenance of an adaptive aid. A maximum of $300 per IPC period may be authorized for repair and maintenance of an adaptive aid(s) so the SPT is not required to complete Form 3660 for repair and maintenance funds requests that do not exceed $300. The SPT must include the amount requested on an individual's IPC in the adaptive aids service category.

The SPT must:

  • consider a written assessment from the appropriate licensed professional recommending an adaptive aid;
  • document any discussion about the recommended adaptive aid; and
  • agree that the recommended adaptive aid is necessary and should be purchased.

For purchases of an adaptive aid or medical supply costing over $500, the case management agency (CMA), DSA and individual/legally authorized representative (LAR) must complete and sign Form 3849-A, Specifications for Adaptive Aids/Medical Supplies/Minor Home Modifications, to signify agreement with the specifications.

All individuals must attempt to obtain needed adaptive aids or durable medical equipment through all possible non-waiver resources available to that individual. Medicare and Medicaid are two common resources available to many individuals in the CLASS program that must be accessed prior to requesting an adaptive aid through CLASS.

The CMA must obtain one of the following as proof of non-coverage by Medicaid:

  • a letter from Texas Medicaid Healthcare Partnership (TMHP) that includes:
    • a statement that the requested adaptive aid is denied under the Texas Medicaid Home Health Services or the Texas Health Steps programs; and
    • the reason for the denial, which must not be one of the following:
      • Medicare is the primary source of coverage;
      • information submitted to TMHP was incomplete, missing, insufficient or incorrect;
      • the request was not made in a timely manner; or
      • the adaptive aid must be leased; or
  • a provision from the current Texas Medicaid Providers Procedure Manual stating the requested adaptive aid is not covered by the Texas Medicaid Home Health Services or the Texas Health Steps programs.

In addition to the documentation required above for an individual eligible for Medicare, a CMA must obtain one of the following documents that specifies denial of an adaptive aid:

  • a letter from Cigna Government Services that includes:
    • a statement that the requested adaptive aid is denied under Medicare; and
    • the reason for the denial, which must not be one of the following:
      • information submitted to Cigna Government Services to make payment was incomplete, missing, insufficient or incorrect;
      • the request was not made in a timely manner; or
      • the adaptive aid must be leased;
  • a letter from Cigna Government Services stating that the adaptive aid is approved and the amount to be paid, which must be less than the cost of the requested adaptive aid; or
  • a provision from the current Region C DMERC (Durable Medical Equipment Region C) DMEPOS (Durable Medical Equipment Prosthetics, Orthotics, and Supplies) Supplier Manual stating that the requested adaptive aid is not covered by Medicare.

The following are examples of documentation that are not acceptable as proof of non-coverage:

  • a statement from a Medicaid enrolled durable medical equipment (DME) provider that the adaptive aid requested is not covered by the Texas Medicaid Home Health Services or the Texas Health Steps programs; and
  • a statement from a Medicare DME provider that the adaptive aid requested is not covered by Medicare.

The CMA is responsible for assisting the individual or legally authorized representative (LAR), as necessary, to pursue all non-CLASS resource options for an adaptive aid prior to requesting an adaptive aid through CLASS. Some examples may include private insurance coverage or other state or local program resources for which the individual may be eligible.

Within five business days of receipt of this record, the CMA must provide copies of all documentation to the DSA verifying that non-CLASS resources were exhausted.

As specified in the instructions for Form 3660, the case manager provides Form 3660 to the individual/LAR when an adaptive aid, medical supply, minor home modification, dental service or dental sedation is requested. Form instructions for Part A specify this section must be completed by the case manager or individual/LAR. Additionally, the case manager completes Part B before the form is then provided to the DSA. DSAs must arrange for the appropriate professional, practicing within the scope of licensure, and as identified adjacent to each adaptive aid listed below to complete Part C of Form 3660. The DSA representative completes Part D. The DSA then submits Form 3660 to the case manager along with written documentation as outlined in 3500, Service Initiation.

For adaptive aids with a cost of $500 or higher, a DSA must obtain comparable bids for the requested adaptive aid from three vendors. Comparable bids describe the adaptive aid and any associated items or modifications identified in an assessment for an adaptive aid. A bid must:

  • state the total cost of the requested adaptive aid;
  • include the name, address and telephone number of the vendor;
  • include a complete description of the adaptive aid and any associated items, modifications or specifications, which may include pictures or other descriptive information from a catalog, website or brochure;
  • include the number of hours of direct service to be provided and the hourly rate of the service (only for those adaptive aids that are services); and
  • be obtained within one year after the written assessment is obtained.

A DSA may obtain only one bid for the following adaptive aids:

  • eyeglasses;
  • hearing aids, batteries and repairs; and
  • orthotic devices, orthopedic shoes and braces.

A DSA may obtain only one bid or two comparable bids for an adaptive aid if the DSA has written justification for obtaining less than three bids because the adaptive aid is available from a limited number of vendors.

If a DSA requests authorization for payment for an adaptive aid that is not based on the lowest bid, the DSA must have written justification for payment of a higher bid.

The following are examples of justifications that support payment of a higher bid:

  • the higher bid is based on the inclusion of a longer warranty for the adaptive aid; and
  • the higher bid is from a vendor that is more accessible to the individual than another vendor.

The only items and services purchasable by the DSA as adaptive aids are listed in this appendix. The maximum amount HHSC authorizes as payment to the DSA for all adaptive aids purchased for an individual receiving CLASS program services is $10,000 per IPC period.

With the exception of a vehicle modification, all adaptive aids purchased for an individual through the CLASS program are the exclusive property of that individual.

The CLASS program does not purchase adaptive aids or medical supplies offered as pre-owned, used or refurbished.

Adaptive aids identified on the IPC must include documentation describing how the item or service:

  • is necessary to protect the individual's health and welfare in the community;
  • addresses the individual's related condition;
  • is not available to the individual through any other source, including the Medicaid state plan, other governmental programs, private insurance or the individual's natural supports;
  • enhances an individual's integration in the community and prevents admission to an institution while maintaining and improving independent functioning;
  • is the most appropriate type and amount of CLASS program services to meet the individual's needs; and
  • is cost effective.

Individuals must be assessed by the most qualified, licensed professional who can justify the need and appropriateness of a requested adaptive aid.

Following are licensed professionals who may assess the need for an adaptive aid in the CLASS program.

  • Audiologist (AU) — A person licensed as an audiologist in accordance with Chapter 401 of the Texas Occupations Code.
  • Licensed Psychological Associate (PSA) — A person licensed in accordance with Texas Occupations Code, Chapter 501.
  • Licensed Professional Counselor (LPC) — A person licensed in accordance with Texas Occupations Code, Chapter 503.
  • Licensed Dental Practitioner (DDS) — A person licensed in accordance with Texas Occupations Code, Chapter 251.
  • Dietitian (DI) — A person licensed as a dietitian in accordance with Chapter 701 of the Texas Occupations Code.
  • Registered Nurse (RN) — A person licensed to practice professional nursing by the Texas Board of Nurse Examiners in accordance with Chapter 301 of the Texas Occupations Code.
  • Physician (MD)(DO) — A person licensed as a physician in accordance with the Texas Occupations Code, Chapter 155. This includes professionals practicing as a medical doctor or as a doctor of osteopathic medicine.
  • Occupational Therapist (OT) — A person licensed as an occupational therapist in accordance with Chapter 454 of the Texas Occupations Code.
  • Ophthalmology (OPH) — A person licensed as a physician in accordance with the Texas Occupations Code, Chapter 155, and certified by the American Board of Ophthalmology.
  • Optometrist (OPT) — A person licensed as an optometrist or therapeutic optometrist in accordance with the Texas Occupations Code, Chapter 351.
  • Physical Therapist (PT) — A person licensed as a physical therapist in accordance with Chapter 453 of the Texas Occupations Code.
  • Psychologist (PS) — A person licensed as a psychologist, provisionally licensed psychologist or psychological associate in accordance with Chapter 501 of the Texas Occupations Code.
  • Speech-Language Pathologist (SP) — A person licensed as a speech-language pathologist in accordance with Chapter 401 of the Texas Occupations Code.
  • Licensed Clinical Social Worker (SW) — A person licensed as a clinical social worker in accordance with the Texas Occupations Code, Chapter 505.

Other Abbreviations and Numbers

(1) — The item must meet Medicaid standards/specifications.
(2) — Equipment rental is highly recommended by HHSC prior to purchase

Adaptive aids that may be covered in the CLASS program must be included on the following list and include the installation, maintenance and repair of approved items not covered by warranty:

  1. Lifts
    1. wheelchair lifts (OT, PT)
    2. porch or stair lifts (OT, PT)
    3. stairway lifts (only in residences owned by the individual/family) (OT, PT)
    4. bathtub seat lifts (OT, PT)
    5. ceiling lifts that transport the individual around the home via tracks (only in residences owned by the individual and/or family) (OT, PT)
    6. other hydraulic, manual or other electronic lifts (OT, PT)
  2. Mobility Aids (including batteries and chargers) — wheelchairs and scooters for facilitating participation in recreational activities and sports are not covered
    1. manual/electric wheelchairs and necessary accessories (OT, PT, MD, DO)
    2. adult stroller/travel chair (OT, PT)
    3. mobility bases for customized chairs (OT, PT)
    4. braces, crutches, walkers, canes (including white canes) and necessary accessories (OT, PT, MD, DO)
    5. prescribed prosthetic devices (OT, PT, MD, DO)
    6. orthopedic shoes and other prescribed footwear (2) (OT, PT, MD)
    7. bus passes, metro transit services, taxi services for non-medical transportation only (for specific purposes related to individual's habilitation goals; not to be used in lieu of medical transportation) (any listed licensed professional)
    8. portable ramps that do not require installation (OT, PT)
    9. automatic door openers (OT, PT)
    10. gait trainer (OT, PT)
    11. mobility aids for individuals with a diagnosed visual impairment listed on the Approved Diagnostic Codes for Persons with Related Conditions, such as:
      • materials to construct adaptive mobility aids (for example, PVC pipes to construct an adapted cane or pre-cane device); (OT, PT, MD, DO, OPH, OPT)
      • color contrast or reflective tape (to mark paths, drop-offs, etc); (OT, PT, MD, DO, OPH, OPT)
      • global positioning systems (GPS) and appropriate accessories to allow independent travel within the community; (OT, PT, MD, DO, OPH, OPT)
      • tinted glasses, visors and sunshields to regulate glare; (OT, PT, MD, DO, OPH, OPT)
      • flashlights; (OT, PT, MD, DO, OPH, OPT) and
      • magnifying devices. (OT, PT, MD, DO, OPH, OPT)
  3. Position Devices
    1. standing frames/boards (OT, PT)
    2. removable bathtub rails (OT, PT)
    3. toilet chair (OT, PT)
    4. orthotic devices (OT, PT, MD, DO)
    5. hospital beds and necessary accessories (must meet Medicaid standards/specifications) (OT, PT)
    6. egg crate mattresses, sheepskin and other medically related padding (OT, PT, MD, DO)
    7. lift recliners (OT, PT)
    8. trapeze bars (OT, PT)
  4. Communication Aids
    1. communicators
      1. direct selection communicators (SP)
      2. alphanumeric communicators (SP)
      3. scanning communicators (SP)
      4. adapted telephones for an individual diagnosed with visual and/or hearing impairments listed on the Approved Diagnostic Codes for Persons with Related Conditions (for example, amplified telephones, phones with enlarged keypads, phones with Braille displays, captioned telephones and speaker phones for people who cannot use conventional telephones) (SP, OT)
      5. Telecommunication Device for the Deaf (TDD) or telephone typewriter/ teletypewriter (TTY) machines with Braille displays (SP)
      6. Video relay phone and equipment for video relay service (the monthly service fee is not included or covered) (SP)
      7. telebraille and teletype machines (SP)
      8. materials to construct communication aids (SP, PS, PSA, LPC, OT)
      9. communication books, communication symbols, experience books and calendar systems (to include calendar boxes, shelves and charts) (PS, PSA, LPC, LCSW)
      10. speech amplifiers and assistive listening devices (SP, OT)
    2. hearing aids beyond the Medicaid limit (SP, AU)
    3. hearing aid supplies beyond the Medicaid limit (SP, AU, MD, DO, RN)
    4. sign language interpreter service for non-routine communications, such as SPT meetings or medical/professional appointments (SP, PS, PSA, LPC, AU, MD, DO)
  5. Computers and Appropriate Accessories

    The following items may be purchased under the adaptive aids category for communication needs not met by an augmentative communication device, to operate adaptive software, for assistance with money management or for environmental control purposes.
    1. computers and appropriate accessories (OT, PT, SP)
    2. appropriate software to address the needs listed above (limited to three per year) (OT, PT, SP)
    3. adapted workstations/chairs (OT, PT, SP)
    4. Braille displays (OT, PT, SP)
    5. Braille printers/embossers (OT, PT, SP)
    6. electronic Braille note takers (OT, PT, SP)
  6. Environmental Controls
    1. electronic environmental control devices (OT)
    2. voice activated, light activated and motion activated devices (to include amplified features) (OT)
    3. control switches/pneumatic switches and devices (OT)
      1. sip and puff controls (OT)
      2. adaptive switches/devices (OT)
      3. sensory adaptations (OT)
  7. Adaptive Equipment for Activities of Daily Living
    The following are based on the needs of the individual as authorized on the Individual Program Plan.
    1. assistive devices
      1. reachers (OT, PT, MD, DO, RN)
      2. stabilizing devices (OT, PT, MD, DO)
      3. weighted equipment (OT, PT, PS, PSA, LPC)
      4. holders (for example, book stands, page turners, cup holder) (OT, PT, MD, DO, RN)
      5. signature stamp or signature guide (OT, PT, MD, DO, RN, OPT, OPH)
      6. electric self-feeders (OT, PT) (2)
      7. microwave ovens (only for individuals with muscular weakness or who lack manual dexterity and those individuals who cannot use conventional ovens) (OT, PT)
      8. food processors and blenders (only for individuals with muscular weakness in upper body or who lack manual dexterity and are unable to use manual conventional kitchen appliances or for individuals with visual impairment that would be necessary for the individuals' safety) (OT, PT, DI)
      9. Electric toothbrush or waterpik device (only for individuals with muscular weakness in upper body or who lack manual dexterity) (DDS, OT, PT)
      10. variations of everyday equipment
        1. shaped, bent, built-up utensils (OT, PT, DI)
        2. long-handed equipment (OT, PT, DI)
        3. addition of friction coverings (OT, PT, DI)
        4. coated feeding equipment (OT, PT, DI)
        5. count-a-medication dose systems/manual medication reminder systems (OT, PT, MD, DO, RN)
        6. pill crushers/splitter (OT, PT, MD, DO, RN)
        7. specially adapted kitchen appliances (OT, PT, DI)
        8. toilet seat reducer rings (OT, PT, MD, DO, RN)
        9. food preparation utensils (OT, PT, DI)
        10. specially adapted clocks/wristwatches for individuals with visual or hearing impairment (OT, PT, AU, OPH, OPT)
        11. adapted scale (OP, PT, MD, DO, RN, DI)
        12. prescribed therapy aids (to be used with therapist oversight) (OT, PT, OPT, OPH, SP, PS, PSA, LPS, DI)
        13. service animals and required maintenance (cost effectiveness of medical intervention to be determined on an individual basis) (OT, MD, DO, OPH)
        14. quad gloves (OT, PT, MD, DO, RN)
    2. safety devices
      1. bed rails (OT, PT, MD, DO, RN, PS, PSA, LPC)
      2. safety padding (OT, PT, MD, DO, RN, PS, PSA, LPC)
      3. helmets (OT, PT, MD, DO, RN, PS, PSA, LPC)
      4. walking belts/gait belts (OT, PT, MD, DO, RN)
      5. flutter boards (OT, PT, MD, DO)
      6. personal floatation devices (in context with therapeutic purposes) (OT, PT, MD, DO)
      7. elbow and knee pads (OT, PT, MD, DO, RN, PS, PSA, LPC)
      8. emergency response service; (backup systems and supports used to ensure continuity of services and supports to include electronic devices and an array of available technology, personal emergency response systems and other mobile communication devices). (OT, PT, MD, DO, RN)
      9. water walkers (OT, PT, MD, DO)
      10. adapted fire extinguishers (OT, PT, MD, DO, RN)
      11. adapted smoke and CO² extinguishers (OT, PT, MD, DO, RN)
      12. visual alert systems (OT,PT, OPT, OPH)
      13. vibrating alert systems (OT, PT)
      14. auditory alert system (OT, PT, MD, DO RN)
    3. shower chairs/transfer benches (OT, PT, MD, DO)
    4. electric razors (for individuals with muscular weakness or who lack manual dexterity and those individuals who cannot use conventional hygiene tools) (OT, PT, MD, DO, RN)
    5. flexible, disposable drinking straws for individuals with muscular weakness or who cannot drink from a regular drinking glass or cup (OT, PT, MD, DO, RN)
    6. hand-held shower attachments that are portable and do not require installation (OT, PT, MD, DO, RN)
  8. Medically Necessary Supplies
    1. tracheostomy care (MD, DO, RN)
    2. decubitus care (MD, DO, RN)
    3. ostomy care (MD, DO, RN)
    4. respirator/ventilator care (MD, DO, RN)
    5. catheterization (MD, DO, RN)
    6. diapers, linens and other incontinence supplies not covered by the Medicaid state plan (MD, DO, RN)
    7. nutritional supplements (MD, DO, RN, DI)
    8. internal feeding formulas and supplies (MD, DO, RN, DI)
    9. transcutaneous electrical nerve stimulation (TENS) units/supplies/repairs (OT, PT, MD, DO, RN)
    10. specialized thermometers (OT, PT, MD, DO, RN)
    11. diabetic supplies (OT, PT, MD, DO, RN, DI)
    12. glucose monitors (OT, PT, MD, DO, RN, DI)
    13. medical supply cabinets (OT, PT, MD, DO, RN)
    14. humidifiers (OT, PT, MD, DO, RN)
    15. suctioning devices (MD, DO, RN)
    16. prescription eyeglasses/accessories beyond Medicaid limit (OPT, OPH)
    17. muscle stimulators (OT, PT, MD, DO, RN)
    18. medically necessary heating and cooling units prescribed by a physician for individuals with respiratory or cardiac problems or people who cannot regulate their body temperature (MD, DO)
    19. urinary incontinence devices and supplies (MD, DO, RN)
    20. blood pressure monitors (MD, DO, RN)
    21. vitamins with a prescription not covered by Medicaid and identified as available previously in this Appendix (MD, DO)
    22. gloves (beyond Medicaid limit) excluding non-sterile gloves per the Occupational Safety and Health Standards included in Code of Federal Regulations 1910 §1910.138(a)-(b) when they are for the protection of the employee (MD, DO, RN)
    23. medication cups (beyond Medicaid limit) (MD, DO, RN)
  9. Specialized Training and Instructions
    1. computer literacy training to educate individuals in use of adaptive software necessary to perform activities of daily living and prevent institutionalization (limited to 10 sessions per software unit) (OT, PT, SLP)
    2. driving lessons for vehicles fitted with adaptive equipment (OT, PT, MD, DO)
  10. Modification/Additions to Primary Transportation Vehicles

    A vehicle lift adaptation may be approved for a vehicle owned by an individual or an individual's family member if it is the primary mode of transportation for the individual, but it cannot exceed one lift/ramp modification every five years. Repairs and maintenance not covered by warranty are not limited to the five-year requirement.

    A vehicle that is expected to be modified or adapted with any of the items/services listed in A. through K. below must meet one of the following criteria:
    • vehicle is less than 5 years old and mileage is less than 50,000 miles; or
    • vehicle passed an independent inspection performed by a certified automotive technician using the Form XXXX CLASS Used Vehicle Evaluation.
      1. vehicle lifts (OT, PT, MD, DO)
      2. vehicle ramps (OT, PT, MD, DO)
      3. wheelchair/scooter lifts and carriers (OT, PT, MD, DO)
      4. turning/transfer seats (OT, PT, MD, DO)
      5. driving controls
        1. brake/accelerator hand controls (OT, PT, MD, DO)
        2. dimmer relays/switches (OT, PT, MD, DO)
        3. horn buttons (OT, PT, MD, DO)
        4. wrist supports (OT, PT, MD, DO)
        5. hand extensions (OT, PT, MD, DO)
        6. left foot gas pedals (OT, PT, MD, DO)
        7. right turn levers (OT, PT, MD, DO)
        8. gear shift levers (OT, PT, MD, DO)
        9. steering spinners (OT, PT, MD, DO)
      6. medically necessary air conditioning unit prescribed by a physician
        for individuals with respiratory or cardiac problems or people who can't
        regulate their body temperature (MD, DO)
      7. removal or placement of seats to accommodate a wheelchair (OT, PT, MD, DO)
      8. installation, adjustment or placement of mirrors to overcome visual obstructions of wheelchair in vehicle (OT, PT, MD, DO)
      9. raising of the roof/lowering of the floor/modifying the suspension
        of the vehicle to accommodate an individual riding in a wheelchair (OT, PT, MD, DO)
      10. manual wheelchair tie-downs/electronic wheelchair restraints (OT, PT, MD, DO)
      11. seat belt covers (OT, PT, MD, PS, PSA, LPC)
      12. automatic door openers (OT, PT, MD, DO)
  11. Repair and maintenance of items on the authorized list above as allowable by rule.
  12. Temporary lease/rental of DME to allow for repair, purchase or replacement of an essential support system or while non-CLASS resources reviews the necessity of an adaptive aid for an individual. Lease/rental shall not exceed 90 days.

Exception

This section does not include all adaptive aids that are excluded from funding by the CLASS program. Unlimited prescribed medications beyond the three per month limit available under the Texas Medicaid State Plan are provided to individuals enrolled in the waiver through the managed care organization providing acute care services. An individual who is eligible for both Medicaid and Medicare (dually eligible) must obtain prescribed medications through the Medicare Prescription Drug Plan or, for certain medications excluded from Medicare, through the Texas Medicaid State Plan.

Form Resources

The following forms may need to be completed as part of the request process for adaptive aids:

  • Form 3598, Individual Transportation Plan
  • Form 3621, CLASS/CFC – Individual Plan of Care
  • Form 3660, Request for Adaptive Aids, Medical Supplies, Minor Home Modifications or Dental Services/Sedation
  • Form 3849-A, Specifications for Adaptive Aids/Medical Supplies/Minor Home Modifications
  • Form 8605, Documentation of Completion of Purchase
  • Form 8606, Individual Program Plan (IPP)
  • Form 2432, CLASS Vehicle Evaluation

Appendix II, Minor Home Modification Services

Revision 22-1; Effective Aug. 23, 2022

Home modifications are services that assess the need to arrange for and provide modifications, or improvements to the person's living quarters. This allows for community living and ensure safety, security and accessibility. Minor home modifications (MHM) do not include major home renovation, remodeling or construction of additional rooms. By rule, the Community Living Assistance and Support Services (CLASS) program assures that minor home modifications are:

  • cost-effective;
  • associated with the related condition;
  • necessary to avoid institutionalization;
  • provide safe access to the home and community; and
  • improve self-reliance and independence.

Approval of all MHMs identified on the Individual Plan of Care (IPC) must include documentation describing why each item is necessary and how it relates to the individual's disability. Form 3660, Request for Adaptive Aids, Medical Supplies, Minor Home Modifications or Dental Services/Sedation, is required for all requested MHMs. Requests for MHMs that require more information be provided by the appropriate licensed professional (as listed below) or require bids must accompany Form 3660, as applicable.

All assessments for MHMs requested through the CLASS program must:

  • be based on a face-to-face evaluation of the person by the licensed professional, conducted not more than one year before the date of purchase of the MHM;
  • include a description of and a recommendation for a specific MHM listed in this appendix and any associated items or modifications necessary to make the MHM functional;
  • include a diagnosis that is related to the person's need for the MHM (for example, cerebral palsy, quadriplegia or deafness);
  • include a description of the condition related to the diagnosis (for example, unable to ambulate without assistance); and
  • include a description of the specific needs of the person and how the MHM will meet those needs (for example, a person who uses a wheelchair for mobility in his home needs to be able to enter the shower area of his residence safely. In order to achieve this goal, barriers in the bathroom need to be removed and a roll-in shower needs to be created).

Repair and maintenance of items purchased through the CLASS program do not require justification from a medical professional.

The service planning team must:

  • consider a written assessment recommending an MHM;
  • document any discussion about the recommended MHM; and
  • agree that the recommended MHM is necessary and should be purchased.

The case management agency (CMA), direct services agency (DSA) and individual or legally authorized representative (LAR) must complete and sign Form 3849-A, Specifications for Adaptive Aids/Medical Supplies/Minor Home Modifications, to signify agreement with the specifications. Form 3660 is not required to accompany an IPC revision that adds only the cost of obtaining specifications to the IPC.

The DSA must submit Form 3660, along with specifications and bids for any MHM that cost $1,000 or more, to the CMA. The case manager must issue an IPC revision or IPC renewal to obtain a service authorization from the Texas Health and Human Services Commission (HHSC) for the proposed MHM.

For MHMs that cost $1,000 or more, a DSA must obtain comparable bids for the requested MHM from three vendors. Comparable bids describe the MHM and any associated items or modifications identified in an assessment for an MHM. A bid must:

  • state the total cost of the requested MHM;
  • include the name, address and phone number of the vendor;
  • include a complete description of the MHM and any associated items or modifications as identified in a written assessment, which may include pictures or other descriptive information from a catalog, website or brochure; and
  • be obtained within one year after the written assessment.

A DSA may obtain only one bid or two comparable bids for an MHM if the DSA has written justification for obtaining fewer than three bids because the MHM is available from a limited number of vendors.

If a DSA will request authorization for payment for an MHM that is not based on the lowest bid, the DSA must have written justification for payment of a higher bid.

The following are examples of justifications that support payment of a higher bid:

  • the higher bid is based on the inclusion of a longer warranty for the MHM; and
  • the higher bid is from a vendor that is more accessible to the individual than another vendor.

The only MHMs purchasable by the DSA are listed in this appendix. The maximum amount HHSC authorizes as payment to the DSA for all MHMs purchased for a person receiving CLASS program services is $10,000. This is a lifetime limit for the person receiving CLASS program services. After reaching the lifetime maximum cost of $10,000, the person may receive, during an IPC period, a maximum of $300 for repair and maintenance of an MHM purchased through the CLASS program, needed after one year has elapsed from the date the MHM is complete.

MHMs are provided under this waiver when no other financial resource is available or when other available resources have been exhausted. MHMs will not be used to modify homes that are owned or leased by providers of waiver services. Modifications must be for existing structures and must not increase the square footage of the dwelling. Excluded are those adaptations or improvements to the home that are of general utility and are not a direct medical or remedial benefit to the person. This includes carpeting, except to allow independent mobility for persons using crutches, wheelchairs, three-wheel scooters, and other aids which offer increased personal mobility, roof repair and central air conditioning. If alternative solutions exist, modifications will be approved by staff from HHSC based on considerations of cost and comparable functionality.

MHMs have to be assessed by the most qualified licensed professionals who can justify the need and appropriateness of a requested MHM.

The following licensed professionals may assess the need for an MHM in the CLASS program.

  • Audiologist (AU) — A person licensed as an audiologist per Chapter 401 of the Texas Occupations Code.
  • Licensed Psychological Associate (PSA) — A person licensed as a psychological associate per the Texas Occupations Code, Chapter 501.
  • Licensed Professional Counselor (LPC) — A person licensed as a professional counselor per the Texas Occupations Code, Chapter 503.
  • Dietitian (DI) — A person licensed as a dietitian per Chapter 701 of the Texas Occupations Code.
  • Registered Nurse (RN) — A person licensed to practice professional nursing by the Texas Board of Nurse Examiners per Chapter 301 of the Texas Occupations Code.
  • Physician (MD) — A person licensed as a physician per the Texas Occupations Code, Chapter 155.
  • Occupational Therapist (OT) — A person licensed as an occupational therapist per Chapter 454 of the Texas Occupations Code.
  • Ophthalmology (OPH) — A person licensed as a physician per the Texas Occupations Code, Chapter 155, and certified by the American Board of Ophthalmology.
  • Optometrist (OPT) — A person licensed as an optometrist or therapeutic optometrist per the Texas Occupations Code, Chapter 351.
  • Physical Therapist (PT) — A person licensed as a physical therapist per Chapter 453 of the Texas Occupations Code.
  • Psychologist (PS) — A person licensed as a psychologist, provisionally licensed psychologist or psychological per Chapter 501 of the Texas Occupations Code.
  • Speech-Language Pathologist (SP) — A person licensed as a speech-language pathologist per Chapter 401 of the Texas Occupations Code.

Include home modifications that may be covered in the CLASS program. They are on the following list and include the installation, maintenance and repair of approved items not covered by warranty.

  1. Home Modifications
    1. floor leveling (only in residences owned by the individual or family and only when the installation of a ramp is not possible) (OT, PT)
    2. vinyl flooring or industrial grade carpet necessary to ensure the safety of the person, prevent falling, improve mobility and adapt a living space occupied by a beneficiary who is unable to safely use existing floor surface (OT, PT)
    3. medically necessary steam cleaning of walls, carpet, support equipment and upholstery (MD)
    4. roll-in showers (OT, PT)
    5. sink modifications (OT, PT)
    6. sink cut-outs (OT, PT)
    7. bathtub modifications (OT, PT)
    8. water faucet controls (OT, PT)
    9. toilet modifications (OT, PT)
    10. floor urinal and bidet adaptations (OT, PT)
    11. plumbing modifications (OT, PT)
    12. turnaround space modifications (OT, PT)
    13. worktable or work surface adjustments (OT, PT)
    14. cabinet development or adjustments (OT, PT)
  2. Specialized Accessibility, Safety Adaptations and Additions (including repair and maintenance)
    1. ramps (constructed to provide access into and within the home) (OT, PT)
    2. protective awnings over ramps (OT, PT, MD)
    3. door widening (OT, PT, MD)
    4. widening/enlargement of garage or carport to accommodate primary transportation vehicle and to allow people using wheelchairs to enter and exit their adapted vehicles safely (OT, PT)
    5. installation of sidewalk for access from non-connected garage or driveway to residence when existing surface condition is a safety hazard for the person with a disability (OT, PT)
    6. porch or patio leveling (only when the installation of a ramp is not possible) (OT, PT)
    7. grab bars and handrails (OT, PT, MD)
    8. door bells, door scopes and adaptive wall switches (OT, PT)
    9. safety glass, safety alarms (not including home security systems), security door locks, fire safety approved window locks, security window screens and visual alert systems (for example, for people with behavioral problems) (OT, PT, MD, PSA, LPC)
    10. medically necessary air filtering devices (MD)
    11. protective padding and corner guards for walls (OT, PT, MD, PSA, LPC)
    12. recessed lighting with mesh covering and metal dome light covers for people with behavior problems (OT, PT, MD, PSA, LPC)
    13. emergency back-up generators (limited to critical medical equipment) (OT, PT, MD)
    14. medically necessary noise abatement renovations to provide increased sound proofing for people with sensory impairments (OT, PT, MD, PSA, LPC)
    15. lever door handles (OT, PT, MD, RN)
    16. door replacement only when required for accessibility (OT, PT, MD)
    17. intercom systems for people with limited mobility or visual impairment (OT, PT, OPT, OPH)
    18. Video monitoring for people with limited mobility and to ensure health and safety (OT, PT, PSA, LPC, MD)
  3. Repair and maintenance of items on the authorized list above as allowable by rule.
     

Appendix IV, Dental Treatment

Revision 11-1; Effective June 13, 2011

Dental treatment consists of dental services and dental sedation.

Dental services within the Community Living Assistance and Support Services (CLASS) program include the following.

  • Emergency Dental Treatment — Includes procedures necessary to control bleeding, relieve pain and eliminate acute infection; operative procedures that are required to prevent the imminent loss of teeth; and treatment of injuries to the teeth or supporting structures.
  • Routine Preventative Dental Treatment — includes examinations, X-rays, cleanings, sealants, oral prophylaxes and topical fluoride applications.
  • Therapeutic Dental Treatment — Includes fillings; scaling; extractions; crowns; pulp therapy for permanent and primary teeth; restoration of carious permanent and primary teeth; maintenance of space; and limited provision of removable prostheses when masticatory function is impaired, when an existing prosthesis is unserviceable, or when aesthetic considerations interfere with employment or social development.
  • Orthodontic Dental Treatment — Includes treatment of retained deciduous teeth; cross-bite therapy; facial accidents involving severe traumatic deviations; cleft palates with gross malocclusion that will benefit from early treatment; and severe, handicapping malocclusions affecting permanent dentition with a minimum score of 26 as measured on the Handicapping Labio-lingual Deviation Index.

Note: Dental treatment in CLASS does not include cosmetic orthodontia.

Dental sedation in CLASS includes sedation that is necessary to perform dental treatment, including non-routine anesthesia, (for example, intravenous sedation, general anesthesia or sedative therapy prior to routine procedures).

Note: Dental sedation does not include administration of routine local anesthesia.

The maximum amount the Department of Aging and Disability Services (DADS) authorizes as payment for all adaptive aids and dental treatment combined is $10,000 per Individual Plan of Care (IPC) year.

Individuals must exhaust all non-CLASS resources before requesting dental treatment through CLASS.

Note: Individuals under age 21 have access to Texas Health Steps for their dental treatment and as such do not qualify to receive dental treatment in CLASS.

Procurement Process for Dental Services/Dental Sedation

The case management agency (CMA) must:

  • provide general information about the availability of dental services/dental sedation to the individual or legally authorized representative (LAR) during service planning and at any other time upon request by the individual or LAR.
  • inform the individual or LAR about the limitations of dental services/dental sedation as it applies in CLASS.
  • aid the individual or LAR to access non-CLASS resources for needed dental care.
  • complete, with input from the individual or LAR, Part A of Form 3660, CLASS – Request for Adaptive Aids, Medical Supplies, Minor Home Modifications or Dental Services/Sedation.
  • complete Part B of Form 3660.
  • submit Form 3660 to the direct service agency (DSA) selected by the individual or LAR no later than 14 business days from completion of Form 3660, Part A. Note: This form must be signed by the individual or LAR.
  • receive and review the dental treatment plan for the individual.
  • initiate an IPC revision within five business days of receipt of Form 3660 and the treatment plan.
  • transmit an IPC revision signed by all applicable service planning team (SPT) members to DADS at least 30 calendar days before the effective date proposed by the SPT.
  • provide a record of the DADS-approved IPC to all SPT members.
  • monitor service delivery in accordance with the IPC and Individual Program Plan (IPP) and applicable CLASS standards.

The DSA must:

  • complete Form 3660, Part C, within five business days of receipt from the CMA.
  • obtain a written treatment plan from a qualified service provider for dental treatment (a person licensed to practice dentistry, dental surgery or dental hygiene in accordance with Texas Occupations Code, Chapter 256) within 14 business days of receipt of the request (Form 3660). The individuals' preferences in the selection of the service provider for dental treatment should be considered when obtaining the treatment plan.
  • ensure the treatment plan includes a complete description of the proposed dental services, dental sedation service and a breakdown of the cost for each element of the proposed service.
  • provide a copy of the proposed treatment plan to the CMA.

Once the DSA has determined the cost of the requested dental treatment and/or dental sedation, the DSA must request in writing that the case manager initiate an IPC revision. The DSA must inform the individual's case manager of the cost of the requested dental treatment and/or dental sedation.

After reviewing submitted documentation, if DADS determines the requested dental treatment and/or dental sedation meets the standards outlined in this appendix, DADS authorizes the IPC.

The DSA must initiate delivery of the requested dental treatment and/or dental sedation within14 calendar days after the date DADS authorizes the proposed IPC or the effective date of the individual's IPC, as determined by the SPT (whichever is later).

If the DSA cannot provide the dental treatment and/or dental sedation within the time frame described, the DSA must:

  • notify the individual and the individual's case manager, orally or in writing before the 14-day time frame expires, that the dental treatment and/or dental sedation will not be provided within the 14-day time frame; and
  • notify the individual and the individual's case manager of a new proposed date for provision of the dental treatment and/or dental sedation.

Immediate Jeopardy

When an individual requires emergency dental treatment and/or dental sedation, the DSA will provide the services in accordance with Section 3330, Revision, and Section 3510, Immediate Jeopardy. Following provision of emergency dental treatment, the CMA must complete an IPC revision in accordance with Section 2331, Immediate Jeopardy.

Appendix V, ID/RC Processing, for additional information and detailed instructions for DSAs

Revision 22-2; Effective Oct. 1, 2022

General Guidelines for Direct Service Agencies (DSAs)

The DSA is responsible for complying with these guidelines and instructions when completing functional assessments and reassessments for all individuals served by the DSA, according to the Community Living Assistance and Support Services (CLASS) program requirements:

Form 8578, Intellectual Disability/Related Condition (ID/RC) Assessment, and Instructions

List of ICD-10 Approved Diagnostic Codes for Persons with Related Conditions (use for assessments with effective dates on or after Oct. 1, 2022):
https://hhs.texas.gov/sites/default/files/documents/doing-business-with-hhs/providers/health/icd10-codes.pdf

Guidelines for completing the Inventory for Client and Agency Planning (ICAP)/Scales of Independent Behavior – Revised (SIB-R):
ICAPguidelines.pdf

Form 8662, Related Conditions Eligibility Screening Instrument (RCESI), and Instructions

All of these resources can be found on the HHS website: https://hhs.texas.gov/

The ID/RC Assessment is the document that contains all of the information required to determine an individual’s initial and continuing eligibility for the CLASS program. The ID/RC summarizes demographic, diagnostic and functional information about the individual.

The tools used to determine functional ability are the RCESI and the Adaptive Behavior Level (ABL) assessment tool. The DSA may select from among four ABL tools for use in the CLASS program: the ICAP, the SIB-R, the Vineland Adaptive Behavior Scales and the American Association of Intellectual and Developmental Disabilities (AAIDD) Adaptive Behavior Scales. The ICAP and SIB-R must be administered by the DSA registered nurse (RN) according to the guidelines noted above. The other two assessments are done by the appropriate professional, usually a licensed psychologist, as identified in the guidelines for the use of these tools. It is up to the DSA to choose the tool used to complete the functional assessments of individuals served by the DSA. The ICAP and the SIB-R must be purchased and licensed through Riverside Publishing (https://www.hmhco.com/classroom-solutions/assessment (link is external)).

The ID/RC, the RCESI, the ABL assessment tool, and the nursing assessment using the CLASS/DBMD Nursing Assessment form must be completed at the time of enrollment (the CLASS/DBMD Nursing Assessment form is not a required part of the ID/RC packet). The DSA RN must conduct these assessments (with the exception of the Vineland or the AAIDD, as stated above). At the time of the annual re-enrollment, these assessments are repeated, with the exception of the ABL assessment tool, which is required only every five years, or if a situation changes. These documents are completed by an RN because the RN has the professional ability to assess the clinical status of the individual and is required to comply with the contractual obligations of the provider, in addition to following the rules of conduct outlined by the Texas Board of Nurses. All corrections to the above referenced documents must also be made by an RN.

All ID/RC packets must include, at a minimum, Form 8578, Form 8662 and the summary (scoring program) of the ABL assessment results.

Initial Eligibility

ID/RC Purpose Code 2 – Initial application; denote this in field 13 on Form 8578.

The DSA must provide the individual’s physician with a list of the Approved Diagnostic Codes for Persons with Related Conditions (see the link above). From this list, the physician will be asked to identify the diagnosis and associated diagnostic code that is primarily responsible for the individual’s disability. If the individual does not have a diagnosis of a related condition, as identified in the Approved Diagnostic Codes for Persons with Related Conditions, the physician must still indicate a diagnosis for the individual and International Classification of Diseases (ICD) code. The physician must complete the section on Page 3 of the ID/RC to testify to the validity of the information in fields 19 – 27 of the form. The physician must be a licensed MD or DO. The DSA is not required to obtain the physician’s signature in handwritten format; the DSA must comply with applicable Home and Community Support Services Agency (HCSSA) requirements related to the receipt of physician orders, as outlined in 40 Texas Administrative Code, Chapter 97, Subchapter C.

The DSA RN must administer the RCESI and the ABL assessment tool, if an ICAP or SIB-R.

An initial application will not have Individual Plan of Care (IPC) begin or end dates identified on the ID/RC. When the ID/RC is authorized by DADS, a begin date will be assigned, based on the date the packet was received by DADS. After all assessments are completed, the RN completes the ID/RC form, signs and dates the form, and forwards it to the physician for his review and sign-off. When returned by the physician, the ID/RC packet is then mailed to DADS for review.

Instructions for the ID/RC form require the program provider that transmits Form 8578 to maintain the original Form 8578 and all other original forms in the individual’s record.

Continuing Eligibility

ID/RC Purpose Code 3 – Reassessments

Continuing eligibility must be determined at least annually. As with the initial assessment, the DSA RN is required to complete an ID/RC, an RCESI (this must be completed every year) and an ABL assessment (ICAP/SIB-R) if the current one is greater than five years old, or is no longer valid. If the ABL tool is the Vineland or the AAIDD, the DSA will arrange to have this done. If the individual’s situation has not changed since the last submission, a copy of the summary of results (the scoring program) of the current ABL assessment is included in the packet.

The RN will record the IPC begin and end dates. For a reassessment, the ID/RC packet must not be submitted more than 120 calendar days prior to the individual’s IPC begin date. The packet must be submitted no less than 60 calendar days prior to the expiration of the current IPC.

If an ID/RC is reviewed by DADS and is authorized before the IPC begin date, the ID/RC will be approved with the IPC begin date.

If the ID/RC is not received by DADS with complete and accurate information in order to be authorized before the individual’s IPC begin date, the ID/RC will be authorized with the DADS receipt date.

When an ID/RC is approved after the IPC begin date, a Purpose Code E will be required to cover the gap between the individual’s original IPC begin date and the authorized, later date on the Purpose Code 3.

ID/RC Purpose Code E – Required to cover a lapse in eligibility

A Purpose Code E must be completed by the DSA RN to cover the period from the individual’s IPC begin date to the day before the Purpose Code 3 was authorized by DADS. A Purpose Code E is required to document the individual’s continuous program eligibility.

The DSA must:

  • prepare a Purpose Code E if the ID/RC packet with the Purpose Code 3 is not submitted in sufficient time to arrive at DADS by the individual’s IPC begin date;
  • date the completion of the Purpose Code E as the date that it is actually prepared;
  • ensure the Purpose Code E is a separate document (it cannot be a copy of the Purpose Code 3 and it must match the Purpose Code 3 exactly, except for the completion dates);
  • ensure that if a Purpose Code E is submitted separately from the Purpose Code 3, to include a copy of the authorized Purpose Code 3 in the packet and indicate on the Purpose Code E the exact end date for the Purpose Code E (copies of the RCESI and ABL assessment tool are not required with submission of a Purpose Code E to DADS as long as these documents are submitted with a DADS authorized Purpose Code 3); and
  • ensure the IPC begin date for a Purpose Code E is the same as the original IPC begin date.

A Purpose Code E does not require a physician’s signature, even if one is requested for the Purpose Code 3.

Note: In situations that require submission of a Purpose Code E, there can be no break in service provision to the individual.

Form 8578, Intellectual Disability/Related Condition Assessment

Form fields that do not apply – The following fields should always be blank for CLASS:

  • 6 — Component Code;
  • 7 — Case No;
  • 73 — CARE ID;
  • 18 — LON;
  • 29 — IQ;
  • 68 — IQ Instrument; and
  • Page 2 of the ID/RC.

DADS does not issue remands for these fields. Staff are not required to insert "NA" in these fields as NA is understood.

Dates on Form 8578

  • Completion dates for the ID/RC must be on or after the RCESI dates and the date of completion of the ABL assessment, unless it was necessary to conduct a new assessment;
  • Date in field 12 on or before the date in field 58;
  • Date in field 58 on or before the physician’s date on Page 3;
  • If preparing a Purpose Code E, document the date that the form was completed; and
  • If re-typing a form in response to a remand from DADS, document the date that the form was re-typed in field 58, or explain that the form was re-typed in the provider comments section.

Alignment Between Diagnosis and ICD Code

For assessments with effective dates prior to Oct. 1, 2015, the list of ICD-9 approved diagnostic codes for persons with related conditions can be found here.

For assessments with effective dates on or after Oct. 1, 2017, the list of ICD-10 approved diagnostic codes for persons with related conditions can be found at:
https://hhs.texas.gov/sites/default/files/documents/doing-business-with-hhs/providers/health/icd10-codes.pdf.

Diagnoses for eligibility consideration by DADS must be a diagnosis included in the approved list. The individual’s diagnosis must be a valid code documented exactly as the diagnosis is denoted in the list. On or after Oct. 1, 2015, ICD-9 codes will no longer be accepted. ICD-10-CM is composed of codes with three, four, five, six or seven characters. Codes with three characters are included in ICD-10-CM as the heading of a category of codes that may be further subdivided by the use of four, five, six or seven characters to provide greater specificity. A three-character code is to be used only if it is not further subdivided.

An example is H91.9, Unspecified Hearing Loss, which by itself is not a valid code. Examples of valid codes within category H91.9 contain five characters, such as:

H91.90, Unspecified Hearing Loss, Unspecified Ear;
H91.91, Unspecified Hearing Loss, Right Ear;
H91.92, Unspecified Hearing Loss, Left Ear; and
H91.93, Unspecified Hearing Loss, Bilateral.

Notes:

  • Additional digits are needed for most 800 codes (850 is the exception).
  • The diagnosis has to record what is in the list, through the final digit. Example: 854.01
    854. = intracranial injury of other and unspecified nature; .0 = no mention of open intracranial wound; 1 = (from Page 5 of the list) no loss of consciousness; 854.01 = intracranial injury of other and unspecified nature, no intracranial wound, no loss of consciousness.

List the diagnosis associated with the code in the approved list:

  • Text up to the parentheses or semicolon; a specific condition can always be included in parentheses.
  • The text in parentheses usually clarifies a diagnosis or contains other diagnoses that are included in the broader diagnosis; it is not necessary to record these unless the text in parentheses applies. Example: 299.0 Autistic disorder; does the individual have just childhood autism, or does he have infantile psychosis or Kanner’s syndrome?
  • It is acceptable to abbreviate (PDD, CP; "NOS" for unspecified; "no" for without).

The primary diagnosis is the only diagnosis field that is required in CLASS.

  • If secondary or tertiary diagnoses are recorded, they must be documented fully and accurately. Even if the primary diagnosis is an eligible related condition with the correct ICD-9 code, the ID/RC will not be authorized if the additional diagnoses and ICD-9 codes are not accurate.
  • If a secondary or tertiary diagnosis is recorded that is not on the list of Approved Diagnostic Codes, the provider must go to the global ICD-9 to obtain the correct code.

The physician attests to the accuracy of these diagnoses and codes. In the event any changes or modifications are required to these fields, the DSA must obtain the physician’s agreement, as indicated by the signature and date on Page 3.

Problematic Fields on Form 8578

Mistakes in documentation in these fields are common:

  • Previous Residence (16) – This refers to the individual's previous residence, location or program before being enrolled in the CLASS program. Staff may have to ask the family to help determine this value.
  • Recommended LOC (17) – This is usually an ‘8’; put a zero here to indicate that the individual is not eligible for the program; ‘1’ does not apply to the CLASS program.
  • Version Code (21, 25, 28) – This is always ‘9’; may change in 2013.
  • Score Identified by ABL Instrument (74) – For ICAPs, this will contain the same value as in field 33; for SIB-Rs, this is the score represented by X/90; this does not apply to the other ABL tools.
  • Functional Assessment (75) – This is the score from the RCESI and should match what is reported on the assessment. The value will always be between 1 and 6 for those over age 10, and 1 to 4 for those under age 10.

Form 8662, Related Conditions Eligibility Screening Instrument (RCESI)

This assessment measures the functional limitations in the six major areas of life activities. To qualify for CLASS, the individual must have impairments in at least three of the six areas for persons age 10 and over, or three of the four areas for those under age 10 (42 Code of Federal Regulations 45.1010).

Right of the individual to sign:

  • If the individual is an adult with no guardian and is able to respond to the assessment, he may answer for himself and must sign for himself.
  • If the individual has a guardian, the guardian must sign Form 8662. In addition to the guardian’s signature, the individual may sign for himself.
  • No other person can sign for the individual, even if a guardian. The guardian will usually be represented as the informant. If the individual is his own guardian, but is unable to sign or stamp his name, he should make some kind of mark (using hand-over-hand assistance, if necessary). The nurse can note "John’s mark" and her signature on the form is testimony to his signing. If the individual is unable to make a mark even with hand-over-hand, note the reason on the form in the comment section – this is reserved only for rare circumstances.

Use of Informant — If an informant is needed to assist the individual, regardless of legal status, that informant must always sign the form as the informant. If the individual is his own guardian, he must sign the form in addition to the informant.

Note: If the form is altered after the assessment, for instance to remove the name of an informant, the form must be re-signed and dated by the appropriate person(s) to indicate agreement with the change(s).

Consistency Between Activities, the Summary and the ID/RC

  • The Summary in Section 4 (B) 1 must match what is recorded in the individual activities on Pages 1 and 2. The score must match what is on the ID/RC (field 75).
  • Note the age of the individual – Activities E and F are not applicable to children under age 10.
  • Score between 1 and 6:
    • For an individual age 10 and older, the maximum score is 6
    • For a child under age 10, the maximum score is 4.

Adaptive Behavior Level (ABL) Assessment Tool

ICAP, SIB-R, Vineland, AAIDD:

  • Only ICAPs and SIB-Rs are done by DSA RNs.
  • ICAP and SIB-R are very similar and guidelines are the same for both.
  • The DSA RN does face-to-face with the individual, regardless of age.
  • The RN must engage the individual during the time of assessment, even if a minor and even when the RN will make use of an informant to assist in completion of the assessment:
    • RN is the independent, objective observer and assessor of the individual;
    • RN must take into account the information provided by the individual or family (can sometimes be under- or over-estimate of actual abilities);
    • RN observes, may use props, can ask the individual to demonstrate tasks or can generalize from other tasks;
    • RN compiles information from individual/family/attendants/etc., and from the RN’s own observations and knowledge of the individual, to arrive at an independent assessment.
  • Booklet – the supporting clinical documentation for the ABL assessment:
    • must be complete, accurate, and done in permanent pen;
    • must match the scoring program; and
    • the original must be kept in the individual’s file.
  • The transferring DSA must forward all originals in the individual’s case record; if no originals are available, a receiving DSA may want to conduct a new assessment.

Problem Behaviors

  • Not every behavior is a problem; not every problem is serious (per assessment guidelines, that can be found at the following link: https://hhs.texas.gov/sites/default/files/documents/doing-business-with-hhs/providers/long-term-care/lidda/icapguidelines.pdf).
  • Definition of a problem (from the guidelines):
    • Many behaviors, even if listed as examples, may not be problems if they are mild, infrequent or age appropriate.
    • For the purpose of the CLASS assessment, a behavior is not a problem if it does not require the attention or intervention of staff, or if it is not discussed as an issue during the service planning team.
    • Does not include behaviors that are a part of the diagnosis, that are medical problems or for which a behavior plan would not be effective.
  • Criteria for severity (from the guidelines):
    • From least (mild) to most severe (critical).
    • Guidelines help the RN to determine the severity of the problem.
    • This section is to assess what behavior is going to present a problem for the service provider; it does not necessarily matter how serious a behavior may be to a parent or other family member if the behavior is not a factor with regard to direct service provision.
  • Staff record only one problem behavior in a category and do not record the same behavior in more than one category.
  • Staff can record more than one problem in the individual’s record, but must choose only one to report in the assessment document.

The ICAP or SIB-R is an assessment of the individual’s activity in the month directly prior to the time the assessment is conducted:

  • If a behavior occurs less than once a month and did not occur during the previous month, it does not have to be listed.
  • If a behavior is not a problem/not serious, the frequency should be "never."
  • This section is for recording serious problem behavior; if a behavior is not a problem or is not serious, the individual should not be penalized for it.

The ABL is assessed at least every five years, or as necessary if the individual’s situation changes. The ABL assessment must be reviewed at the time of every reassessment to verify continuing accuracy.

  • Children may need to be assessed more frequently.
  • Necessary whenever a situation or needs change.
  • Maintain an original record for the files.

Perform Quality Control Before Submitting ID/RC Packets to DADS

Only the most recent ID/RC packet submission is relevant as this information renews at least annually.

All required forms must be complete and accurate:

  • No blank fields (other than those identified in the instructions).
  • Check consistency – birth dates, onset dates.
  • Check previous Level of Care forms (Form 8578 or Form 3650) – diagnosis, code, birth date, onset date.
  • Ensure that remands have been thoroughly checked and that all remand reasons have been fully addressed.
  • The submission must be within the appropriate time frame.
  • The submission for reassessments must be within the 120- to 60-day time frame.
  • Compare the diagnosis and code against the current DADS List of Approved Diagnostic Codes for Persons with Related Conditions.

Remands

Return all material, including the material that was originally submitted plus all new material and all remand forms, with each re-submission to DADS. DADS must be able to track the history of the packet with each re-submission, including:

  • what has been requested and corrected;
  • who worked the packet before; and
  • all dates must be clearly defined.

Corrections/Additions – Mark through the incorrect value, insert the correct value, initial, and date each correction or addition of missing information. For RCESI or the ABL assessment, provide clear indication of the correct response.

Consistency Within and With Other Information Provided

  • Birth dates; completion dates on other forms;
  • Legal status (field 15), RCESI, ICAP, etc.;
  • ABL Assessment, and ABL (field 30);
  • Field 74 (Score identified by ABL Instrument – same as field 33 for the ICAP); and
  • Behavior Program (field 34), Nursing (39), Day Services (41), Employment Services (44):
    • If a service is indicated, the related fields must be populated, and vice versa.
    • Nursing is a required service and these fields should always be completed for a Purpose Code 3; at the very least this represents the nursing that is allotted on the IPC.
    • Behavior Program (field 34) and fields 35 – 38; if no behavior program, these fields must be 0 and vice versa.

ID/RC Processing Timeline

DADS requires 15 working days to process ID/RC packets. Working days do not include weekend days or state or federal holidays. In addition, the provider must allow four days of mail time from the date the provider mailed the packet, and four days following the DADS processing timeline for the mail to be received back by the provider.

Contact Information

For ID/RC inquiries, staff:

  • Fax a name or a list of individuals to DADS Administrative Assistant at 512-438-5135.
  • Include the name, Medicaid number (or Social Security number), and date the packet is mailed.
  • If not within the processing timeline outlined, wait to inquire until the processing timeline has lapsed.

For questions related to an assessment or status, contact the IDD Waivers Program Enrollment/Utilization Review Unit in Access and Intake at DADS at 512-438-3609.

  • Voice message – Speak slowly and distinctly.
  • Leave name, number and a brief message.

Mail – All ID/RC packets are mailed to DADS unless other arrangements are made.

Regular Mail

Department of Aging and Disability Services
P.O. Box 149030, Mail Code W-521
Austin TX 78714-9030

Priority or Overnight Mail – Physical Address

Department of Aging and Disability Services
701 W. 51st St., Mail Code W-521
Austin, TX 78751

Note: Always include Mail Code W-521 for accurate routing.

CLASS Fax Number – 512-438-5135

Appendix X, IPP Service Summary/IPP Service Review Due Dates Chart

Revision 17-1; Effective November 1, 2017

 

IPP Service Summary/IPP Service Review Due Dates Chart

IPC Renewal Date

 

First DSA/FMSA Summary Due Date First CMA Review Due Date Second DSA/ FMSA Summary Due Date Second CMA Review Due Date Third DSA/ FMSA Summary Due Date Third CMA Review Due Date Earliest Renewal Meeting Date Latest Date to Submit IPC to HHSC
Jan 1 Feb 28 Mar 31 May 31 June 30 Aug 31 Sept 30 Oct 3 Dec 2
Feb 1 Mar 31 April 30 June 30 July 31 Sept 30 Oct 31 Nov 3 Jan 2
Mar 1 April 30 May 31 July 31 Aug 31 Oct 31 Nov 30 Dec 1 Jan 30
April 1 May 31 June 30 Aug 31 Sept 30 Nov 30 Dec 31 Jan 1 Mar 2
May 1 June 30 July 31 Sept 30 Oct 31 Dec 31 Jan 31 Jan 31 April 1
June 1 July 31 Aug 31 Oct 31 Nov 30 Jan 31 Feb 28 Mar 3 May 2
July 1 Aug 31 Sept 30 Nov 30 Dec 31 Feb 28 Mar 31 April 2 June 1
Aug 1 Sept 30 Oct 31 Dec 31 Jan 31 Mar 31 April 30 May 3 July 2
Sept 1 Oct 31 Nov 30 Jan 31 Feb 28 April 30 May 31 June 3 Aug 2
Oct 1 Nov 30 Dec 31 Feb 28 Mar 31 May 31 June 30 July 3 Sept 1
Nov 1 Dec 31 Jan 31 Mar 31 April 30 June 30 July 31 Aug 3 Oct 2
Dec 1 Jan 31 Feb 28 April 30 May 31 July 31 Aug 31 Sept 2 Nov 1

Appendix XI, Retired Information Letters

Revision 13-5; Effective November 19, 2013

 

The Department of Aging and Disability Services (DADS) deployed the revised Community Living Assistance and Support Services (CLASS) Provider Manual in June 2011. This manual contains contract guidelines that were formerly found in Information Letters (ILs).

Content in this manual and the Texas Administrative Code (TAC) supersedes any previous ILs or similar guidance published by DADS. The ILs retired as a result are listed below. DADS recommends that providers remove the ILs from their records to ensure they reference the most current information. Any letters or program guidance issued prior to Internet accessibility is null and void, including policy previously sent by U.S. mail.

Number Title Date Posted Date Removed
IL 2011-31 Complaints Regarding Solicitation 04/15/2011 04/30/2019
IL 2010-59 Policy Clarification Regarding Utilization Review in the Community Living Assistance Services and Supports Waiver Program 04/26/2010 06/13/2011
IL 2010-22 Information Letter Clarifying Behavioral Support Services 02/17/2010 06/13/2011
IL 2010-02 Enhancements to the CLASS Program Notification Processes [Note: this letter was withdrawn on 6/3/2010] 05/13/2010 06/03/2010
IL 2009-158 Personal Care Services and CLASS Habilitation 12/11/2009 06/13/2011
IL 2009-127 Rate Increase and IPC Adjustments for CDS 09/09/2009 06/13/2011
IL 2009-120 Expansion of Services Available Through the Consumer Directed Services (CDS) Option in the CLASS Program 09/02/2009 06/13/2011
IL 2009-110 Renewal of CLASS Waiver 08/31/2009 06/13/2011
IL 2008-97 New Service Codes for CDS Respite for the CLASS Program 07/01/2008 06/13/2011
IL 2008-75 Billing Procedures for CMA Vendor Number Transfers 05/23/2008 06/13/2011
IL 2008-64 Revisions to Forms 3621 and 3621-T 05/23/2008 06/13/2011
IL 2008-34 Nursing Services Billing 03/05/2008 06/13/2011
IL 2008-19 Correction to Form 3621 02/12/2008 06/13/2011
IL 2008-127 Utilization Review of Individual Service Plans (ISPs) 09/04/2008 06/13/2011
IL 2008-123 Behavioral Support Services 08/22/2008 06/13/2011
IL 2008-11 CLASS Utilization Review and Cost Ceiling 01/24/2008 06/13/2011
IL 2007-59 CLASS Transfer Process (Clarifies transfer process) 06/20/2007 06/13/2011
IL 2007-57 Billing Procedures for CMA and DSA Pre-Assessments 06/29/2007 06/13/2011
IL 2007-46 CLASS Individual Service Plan and Billing Processes (Billing Info) 06/20/2007 06/13/2011
IL 2007-16 Discontinuation of Payment for Monthly Service Fees for Communication Devices (No monthly bills) 04/04/2007 06/13/2011
IL 2007-120 Additional Information for Coordinating CLASS Enrollments when Applicants Are Currently Receiving Assistance from Personal Care Services (PCS) (This letter was rescinded 11/21/2008) 11/15/2007 11/21/2008
IL 2007-116 Addition of Specialized Nursing 12/07/2007 06/13/2011
IL 2007-104 Addition of Specialized Therapies Requisition Fee 10/19/2007 06/13/2011
IL 2006-95 New CLASS Form 1351 -- Decline of Offer for CLASS Program Enrollment (New form) 11/15/2006 06/13/2011
PL 2004-22 /
IL 2004-36
Documents from the Texas Department of Human Services after September 1, 2004 08/10/2004 06/13/2011
IL 2004-34 New Medicaid Waiver Service of Support Family Services 07/14/2004 06/13/2011
IL 2001-17 Electronic Access to Program Rules and Handbooks (All letters, manuals and TAC on web) 09/14/2001 06/13/2011
CMS 2001-07 Claims Information (Claims and end of FY) 07/13/2001 06/13/2011
CMS 2001-02 Miscellaneous Claims (Claims paid after end of fiscal year) 03/30/2001 06/13/2011
CMS 2001-01 Loss of Medicaid Eligibility Report (How providers learn of ME loss) 12/28/2000 06/13/2011
CMS 2000-10 Procedures for Overlapping Services in the Service Authorization System (SAS) / Claims Management System (CMS) (Info for SO staff) 01/31/2001 06/13/2011
CMS 2000-08 Most Common NHIC Errors and SAS Causes 11/22/2000 06/13/2011
CMS 2000-06 New R&S Report (Enhancements made to R&S Report take effect on 8/14/00.) 08/04/2000 06/13/2011
CLASS2002-05 Program Terminology and Staff Orientation (Remove 24 hour training requirement) 09/23/2002 06/13/2011
CLASS2002-04 Adaptive Aids, Minor Home Modifications, and Medical Supplies 04/19/2002 06/13/2011
CLASS2002-02 Cost Ceilings in the CLASS Program 02/08/2002 06/13/2011
CLASS2002-01 Level-of-Care determination for CLASS participants 01/17/2002 06/13/2011
CLASS2001-04 Respite Care 11/09/2001 06/13/2011
CLASS2001-03 Calculating Requisition Fees and Participant-Requested for Upgrades 11/15/2001 06/13/2011
CLASS2001-02 Appropriation Riders, 77th Legislative Session 09/19/2001 06/13/2011
CLASS2001-01 Updated Procedures for Processing Form 3621, Page 1, Individual Service Plan 06/15/2001 06/13/2011
CLASS2000-05 Documentation of Services Delivered, Form 3625 09/01/2000 06/13/2011
CLASS2000-04 Individual Service Plan, Form 3621-1 08/24/2000 06/13/2011
CLASS2000-03 Updated List of ICD-9-CM Diagnostic Codes for Persons with Related Conditions 07/27/2000 06/13/2011
CLASS2000-01 Procedures for completing and submitting the Level-of-Care and attachment(s) 07/15/2000 06/13/2011
CLASS1999-16 Changes to the instructions on Form 3625, Documentation of Services Delivered 01/20/2000 06/13/2011
CLASS1999-08 Updated List of ICD-9-CM Diagnostic Codes for Persons with Related Conditions 08/19/1999 06/13/2011
CLASS1999-04 CLASS Policy Clarification No. 99004 (Updated list of ICD-9-CM & Form 3650-A/B Instructions) 04/15/1999 06/13/2011
CLASS1999-02 Documentation requirements for purchase of computers and accessories through the CLASS Program 03/19/1999 06/13/2011
CLASS 2004-03 Request for Hearings 11/05/2004 06/13/2011
CLASS 2004-02 Implementation Procedures for Rider 7(b)(2) in the CLASS Program 10/22/2004 06/13/2011
CLASS 2004-01 Implementation of Support Family Services (SFS Introduced. NF residents, under 18, discharged into the CLASS offered SFS as an alternative to residing with their natural family.) 08/25/2004 06/13/2011
CLASS 2003-04 Revised List of Approved Service and Billing Codes for CLASS (HHSC approved rates for CLASS CDSA providers for SFY 2004 and 2005.) 08/29/2003 06/13/2011
CLASS 2003-03 Class Rate Changes, Effective September 1, 2003 (HHSC approved rates for CLASS providers for SFY 2004 and 2005) 08/29/2003 06/13/2011
CLASS 2003-02 Revised List of Approved Service and Billing Codes for CLASS (CLASS providers must use approved service codes and billing codes on or after September 1, 2003. If not used, the claim will be rejected.) 08/26/2003 06/13/2011
CLASS 2003-01 Follow-Up to CLASS Info letter No. 02-02 Rate Changes (CDSA requirements for monitoring usage) 02/10/2003 06/13/2011
CLASS 2002-03 Follow-Up to CLASS Info letter No. 02-02 - Rate Changes (CDS rate changes) 10/04/2002 06/13/2011
CLASS 2002-02 Rate Changes 07/26/2002 06/13/2011
CLASS 2001-02 CLASS Rate Changes 08/28/2001 06/13/2011
CLASS 2001-01 Frequently Asked Questions (FAQ's) (Supervisory Visits, IPC Change, CMA billing w/Transfer, Sleeping during respite) 06/26/2001 06/13/2011
CLASS 2000-01 Correction to Info letter #2000-01 CLASS Rate Changes and New Service Cap 09/29/2000 06/13/2011
CLASS 1999-30 Re-issuance of Info letter #1999-30 - New/Amended Client Eligibility Rules 07/01/2000 06/13/2011
CLASS 1999-12 Revised CLASS Forms 07/09/1999 06/13/2011
CLASS 1999-06 New Rules for CLASS Provider Agencies (New TAC introduced) 03/31/1999 11/19/2013

If there are questions about the CLASS provider manual or any of the letters that were retired, send an email message to class@hhsc.state.tx.us.

Appendix XV, Abuse, Neglect, and Exploitation Training and Competency Test

Revision 19-3; Effective June 7, 2019

 

1. Requirement to Train Staff Persons, Service Providers, and Volunteers

A Community Living Assistance and Support Services (CLASS) case management agency (CMA) and direct services agency (DSA) must ensure their staff persons, service providers and volunteers are:

  1. trained on:
    • acts that constitute abuse, neglect and exploitation;
    • signs and symptoms of abuse, neglect and exploitation; and
    • methods to prevent abuse, neglect and exploitation; and
  2. knowledgeable of:
    • acts that constitute abuse, neglect and exploitation;
    • signs and symptoms of abuse, neglect and exploitation; and
    • methods to prevent abuse, neglect and exploitation; and
  3. instructed to report to Department of Family and Protective Services (DFPS) immediately, but not later than 24 hours, after having knowledge or suspicion that an individual has been, or is being, abused, neglected or exploited by:
  4. provided with these instructions described in paragraph c of this section, in writing.

 

2. Optional Computer-Based Training

A CLASS CMA and DSA have the option of requiring their staff persons, service providers and volunteers to complete the Health and Human Services Commission’s (HHSC’s) ANE Competency Training.

The completion of the computer-based training by staff persons, service providers and volunteers meets the requirement in Section 1a of this appendix.

Staff members, service providers and volunteers must first sign up on the Learning Portal to have access to HHSC approved trainings, including this one for ANE, entitled ANE Competency Training and Exam (online). The ANE training is found in Medicaid Long Term Services and Supports Training under the Health and Human Services Commission Courses tab.

Link to the Learning Portal homepage: https://learningportal.hhs.texas.gov/

 

3. Mandatory Computer-Based Competency Test

A CMA and DSA must ensure that a person trained on abuse, neglect and exploitation, as required by Section 1a of this appendix, completes HHSC’s ANE Competency Final Test and receives a score of at least 80 percent.

Compliance with this section by staff persons, service providers and volunteers meets the requirement in Section 1b of this appendix.

Section 2 provides information on how to access the Competency Test on the Learning Portal.

 

4. When Compliance Must Begin and Frequency of Training

A CLASS CMA and DSA must ensure that the requirements in Section 1 of this appendix are met:

  • for a staff person, service provider or volunteer who is hired on or after July 1, 2019, before the staff person, service provider or volunteer assumes job duties, and annually thereafter; and
  • for a staff person, service provider or volunteer who is hired before July 1, 2019, within one year after the person’s most recent training on abuse, neglect and exploitation, and annually thereafter.

 

5. Documentation Requirements

A CLASS CMA and DSA must:

  1. document:
    • the name of the person who received the training required by Section 1a of this appendix;
    • the date the training was conducted; and
    • one of the following:
      • the name of the person who conducted the training; or
      • if the training is not in-person training, a description of the type of training provided; and
  2. maintain a copy of the certificate generated from the HHSC’s ANE Competency Final Test for each staff person, service provider, and volunteer.

Appendix XVI, Value-added Services

Revision 19-5; Effective November 25, 2019 

 

Value-added services (VAS) are extra benefits offered by managed care organizations (MCOs) beyond the Medicaid-covered services. VAS may include routine dental, vision, podiatry, and health and wellness services. VAS may be actual health care services, benefits or positive incentives that Texas Health and Human Services Commission determines will promote healthy lifestyles and improve health outcomes among members. Each MCO offers a different set of VAS and the MCO can change the VAS it offers once per fiscal year beginning September 1.
 
MCOs must cover all benefits in Medicaid managed care programs, such as STAR+PLUS, STAR Kids and STAR Health. The MCOs use VAS as an incentive to assist the member in making the best plan choice. In addition, members may use VAS to help choose which MCO has the added benefits best suited for their needs. 

VAS are not considered non-waiver resources and therefore, waiver program providers do not consider VAS offered by the MCO when considering third-party resources. VAS is an added benefit available to individuals from the MCO providing their acute care services.

Appendix XVII, Definition of the Term “Relative”

Revision 21-1; Effective June 23, 2021

A person is considered to be a relative if the person is related within the fourth degree of consanguinity or within the second degree of affinity.

Relationships of Consanguinity

Two people are related to each other by consanguinity if one is a descendant of the other or if they share a common ancestor. An adopted child is considered to be a child of the adoptive parent for this purpose.

Degrees of Consanguinity

Individual1st Degree2nd Degree3rd Degree4th Degree
Personchild
parent
grandchild,
sister, brother,
grandparent
great grandchild,
niece, nephew,
*aunt, *uncle,
great grandparent
great-great grandchild,
grandniece, grandnephew, first cousin,
*great aunt, *great uncle,
great-great grandparent

*An aunt, uncle, great aunt or great uncle is related to a person by consanguinity only if he or she is the sibling of the person's parent or grandparent.

Example: Person A is related by the third degree of consanguinity to person B if person B is person A's uncle (brother of person A's father) because they share a common ancestor. However, person A is not related by consanguinity to person C if person C is the uncle's spouse because person A and person C share no common ancestor.

Relationships of Affinity

Two people are related by affinity if they are married to each other, or if one person’s spouse is related by consanguinity to the other person.

The ending of a marriage between two people by divorce or the death of a spouse ends relationships by affinity created by that marriage, unless a child of that marriage is living, in which case the marriage is considered to continue as long as a child of that marriage lives.

Degrees of Affinity

Individual1st Degree2nd Degree
Personspouse
spouse’s child (stepchild)
spouse’s parent
child’s spouse
parent’s spouse (stepparent)
spouse's grandchild (step grandchild)
spouse's brother,
spouse’s sister
spouse's grandparent
grandchild's spouse
brother’s spouse,
sister’s spouse
grandparent’s spouse (step grandparent)

Example: Person A is related by the second degree of affinity to the brother of person A's spouse because the brother and Person A’s spouse are related by the second degree of consanguinity.

Appendix XVIII, CLASS Program Provider Computer-Based Training and Competency Test

Revision 20-3; Effective May 27, 2020

 

1. Requirements to Train Staff Persons

Community Living Assistance and Support Services (CLASS) case management agencies (CMAs) and direct services agencies (DSAs) must ensure their case managers and program directors are trained and knowledgeable about the CLASS waiver program by completing the CLASS Policy and Process Training and final test.

The computer-based training provides guidance on how to successfully develop, complete and submit required paperwork to Texas Health and Human Services Commission (HHSC) for review. This includes:

  • Submission of enrollment, renewal, revision, termination and transfer individual plan of care (IPC) packets;
  • Suspension requirements and submissions; and
  • Packet submission standards, including:
    • completing forms; and
    • common mistakes.

The computer-based training does not replace the in-person CLASS provider training provided biannually by HHSC, as required by Texas Administrative Code §45.704 and §45.804 and CLASS Provider Manual Section 2121, Initial Training for Staff with Direct Contact, and Section 3121, Initial Training for Direct Contact Staff.

 

2. Mandatory Computer-Based Training and Competency Test

To comply with the training requirement, CMAs and DSAs must ensure that their case managers and program directors complete HHSC’s online training titled “CLASS Policy and Process Training” and receive a score of at least 80% on the final test.

Case managers and program directors must create an account on the Learning Portal to have access to HHSC approved trainings, including the online CLASS Policy and Process Training (online). This training is found in the HHSC Courses section under the Medicaid Long Term Services and Supports Training tab. The final test is at the end of the training. A certificate will be generated when the training and test are complete.

Link to the Learning Portal homepage: https://learningportal.hhs.texas.gov/

 

3. Compliance and Frequency

CLASS CMAs and DSAs must ensure that case managers and program directors complete the required training and receive a score of at least 80% on the final test as follows:

  • No later than Aug. 31, 2020, and annually thereafter for all current case managers and program directors; and
  • Before the case manager and program director assumes job duties and annually thereafter if the person is hired on or after June 1, 2020.

 

4. Documentation

CLASS CMAs and DSAs must do the following for all case managers and program directors:

  • Maintain a list that includes each person’s name and the date each person completed the CLASS Policy and Process Training and received a score of at least 80% on the final test; and
  • Maintain a copy of the certificates generated from the HHSC CLASS Policy and Process Training after each person has competed the final test and received a score of at least 80%.

Forms

ES  = form also available in Spanish.

FormTitle
1290Long Term Care Claim 
1351Request to Withdraw from the CLASS Application ProcessES
1581Consumer Directed Services Option OverviewES
1582Consumer Directed Services ResponsibilitiesES
1583Employee Qualification RequirementsES
1584Consumer Participation ChoiceES
1586Acknowledgement of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) OptionES
1720Appointment of a Designated Representative 
1735Employer and  Employer and Financial Management Services Agency Service Agreement 
1739Service Provider Agreement 
1740Service Backup PlanES
1741Corrective Action PlanES
2067Case Information 
2076Authorization to Release Medical InformationES
2432Community Living Assistance and Support Services (CLASS) and Deaf Blind with Multiple Disabilities (DBMD) Vehicle Evaluation 
3591CLASS IPC/IDRC Cover Sheet 
3595IPP Service Review 
3596PAS/Habilitation Plan - CLASS/DBMD/CFC 
3598Individual Transportation Plan 
3599Habilitation Service Provider Orientation/Supervisory Visits 
3621CLASS/CFC - Individual Plan of Care 
3621-TCLASS/CFC - IPC Service Delivery Transfer Worksheet 
3622Denial of Application for CLASS 
3623Approval of Application for CLASS 
3624Termination, Reduction or Denial of CLASS 
3625CLASS/CFC - Documentation of Services DeliveredES
3627Specialized Nursing Certification 
3628Provider Agency Model Service Backup Plan 
3629Individual Program Plan Addendum 
3657Pre-Enrollment Assessment 
3660Request for Adaptive Aids, Medical Supplies, Minor Home Modifications or Dental Services/Sedation 
3849-ASpecifications for Adaptive Aids/Medical Supplies/Minor Home Modifications 
4800-DFair Hearing Request Summary 
4800-DA4800-D Addendum 
6509CLASS/DBMD Coordination of Care 
6515CLASS/DBMD Nursing Assessment 
8001Medicaid Estate Recovery Program Receipt AcknowledgementES
8401Employment First Discovery Tool 
8507Understanding Program Eligibility - CLASS/DBMD 
8557CLASS/DBMD Corrective Action Plan 
8578Intellectual Disability/Related Condition Assessment 
8598Non-Waiver Services 
8601Verification of Freedom of ChoiceES
8604Transition Assistance Services (TAS) Assessment and Authorization 
8605Documentation of Completion of Purchase 
8606Individual Program Plan (IPP) 
8606-ATherapy Justifications - Attachment to IPP 
8662Related Conditions Eligibility Screening Instrument 
H1200Application for Assistance - Your Texas Benefits 
H1350Opportunity to Register to Vote 
H1746-AMEPD Referral Cover Sheet 
H1826Case Information ReleaseES
H3034Disability Determination Socio-Economic ReportES
H3035Medical Information Release/Disability DeterminationES

22-3, Section 7200 Revised

Revision Notice 22-3; Effective Oct. 25, 2022

The following change(s) were made:

Section Title Change
7230 Therapies Adds information on telehealth therapy services.
7231 Behavioral Support Services
  • Updates billable activities list.
  • Deletes Seclusion information.
7232 Occupational Therapy, Physical Therapy, and Speech and Language Pathology Updates billable activities list.
7233 Specialized Therapies
  • Updates billable activities list.
  • Removes Requisition Fees.
7235 Dietary Services (Nutritional Services) Updates billable activities list.
7236 Auditory Integration/Auditory Enhancement Training Clarifies service must be provided in-person.

22-2, Appendix V Change

Revision Notice 22-2; Effective Oct. 1, 2022

The following change(s) were made:

Section Title Change
Appendix V ID/RC Processing, for additional information and detailed instructions for DSAs Updates effective date and link for ICD-10 Approved Diagnostic Codes for Persons with Related Conditions.

22-1, Appendix II Revised

Revision Notice 22-1; Effective Aug. 23, 2022

The following change(s) were made:

Section Title Change
Appendix II Minor Home Modification Services Removes language

21-1, Appendix XVII Added

Revision Notice 21-1; Effective June 23, 2021

The following change(s) were made:

Section Title Change
Appendix XVII Definition of the Term “Relative” Adds an appendix explaining a person is considered to be a relative if the person is related within the fourth degree of consanguinity or within the second degree of affinity.

Acronyms

Revision 13-2; Effective September 6, 2013

 

AAIDD — American Association of Intellectual and Developmental Disabilities

ABL — Adaptive Behavior Level

ABS — Adaptive Behavior Scales

ADL — Activities of Daily Living

ARD — Admission, Review and Dismissal

CAP — Corrective Action Plan

CAS — Community Attendant Services

CBA — Community Based Alternatives

CDS — Consumer Directed Services

CDSA — Consumer Directed Service Agency

CFS — Continued Family Services

CLASS — Community Living Assistance and Support Services

CMA — Case Management Agency

CMPAS — Consumer Managed Personal Attendant Services

CRS — Consumer Rights and Services

DADS — Department of Aging and Disability Services

DARS — Department of Assistive and Rehabilitative Services

DBMD — Deaf Blind with Multiple Disabilities

DFPS — Department of Family and Protective Services

DR — Designated Representative

DSA — Direct Service Agency

DSHS — Department of State Health Services

ERS — Emergency Response Services

EVV — Electronic Visit Verification

FC — Family Care

FMS — Financial Management Services

FMSA — Financial Management Services Agency

HCS — Home and Community-based Services

HDM — Home-Delivered Meals

HHSC — Health and Human Services Commission

ICAP — Inventory for Client and Agency Planning

ICF/IID — Intermediate Care Facility for Individuals with an Intellectual Disability or Related Conditions

IEP — Individual Education Plan

IHFSP — In-Home and Family Support Program

IPC — Individual Plan of Care

IPP — Individual Program Plan

LA — Local Authority

LAR — Legally Authorized Representative

LOC — Level of Care

MDCP — Medically Dependent Children Program

OT — Occupational Therapy

PDP — Person Directed Planning

PHC — Primary Home Care

PT — Physical Therapy

RC — Residential Care

SARC — Sanction Action Review Committee

SFS — Support Family Services

SIB-R — Scales of Independent Behavior – Revised

SPT — Service Planning Team

SSI — Social Security Income

SSPD — Special Services for Persons with Disabilities (24-Hour)

TAS — Transition Assistance Services

TMHP — Texas Medicaid & Healthcare Partnership

TxHmL — Texas Home Living

UR — Utilization Review

Vineland-II — Vineland Adaptive Behavior Scales, Second Edition

Glossary

Revision 13-2; Effective September 6, 2013

The following words and terms, when used in this manual, have the following meanings unless the context clearly indicates otherwise.

# A C D E F H I L M N P R S T U

§1915(c) Medicaid Waiver — The provision of the Social Security Act that authorizes the secretary of Health and Human Services to grant waivers of certain Medicaid statutory requirements so that a state may furnish home and community-based services to Medicaid beneficiaries who need a level of institutional care that is provided in a hospital, nursing facility or intermediate care facility for persons with intellectual disability (ICF/ID).

# A C D E F H I L M N P R S T U

Abuse — The infliction of injury, unreasonable confinement, intimidations, punishment, mental anguish, sexual abuse or exploitation of an individual. Types of abuse include:

  • physical abuse (a physical act by an individual that may cause physical injury to another individual).
  • psychological abuse (an act, other than verbal, that may inflict emotional harm, invoke fear or humiliate, intimidate, degrade or demean an individual).
  • sexual abuse (an act or attempted act such as rape, incest, sexual molestation, sexual exploitation, sexual harassment or inappropriate or unwanted touching of an individual by another).
  • verbal abuse (using words to threaten, coerce, intimidate, degrade, demean, harass or humiliate an individual).

Activities of Daily Living (ADL) — Basic personal everyday activities that include bathing, dressing, transferring (e.g., from bed to chair), toileting, mobility, eating, grooming, positioning and assisting with self-administration of medication.

Agency Option — A service delivery option in which the provider agency is the employer of record of the direct service provider of a specific CLASS program service.

Applicant — A person who has requested CLASS program services for whom eligibility for CLASS is in the process of being determined.

Appeal — The formal process by which an applicant, individual, or the applicant or individual's parent, guardian or legally authorized representative (LAR) requests a review of an adverse action.

 

# A C D E F H I L M N P R S T U

 

Community Living Assistance and Support Services (CLASS) — A §1915(c) Medicaid waiver program that provides community-based" id="Community">Community Living Assistance and Support Services (CLASS) — A §1915(c) Medicaid waiver program that provides community-based services and supports to people with developmental disabilities other than intellectual disability as an alternative to residing in an intermediate care facility.

Caregiver — A person who helps care for someone who is ill, has a disability, or has functional limitations and requires assistance. Informal caregivers are relatives, friends or others who provide unpaid care. Paid caregivers provide services in exchange for payment for the services rendered.

Case Manager — An employee of the Case Management Agency (CMA) who serves as the focal point for service planning and delivery. Responsibilities include needs assessment and reassessment, development of the service plan, identifying appropriate community resources, monitoring the appropriateness and quality of services, providing crisis intervention and advocacy, safeguarding individual rights, and keeping records.

 

Case Management Services — Services that assist the individual in:

 

  • assessing the individual's needs;
  • enrolling into the CLASS program;
  • developing the Individual's Plan of Care (IPC);
  • coordinating the provision of CLASS program services;
  • monitoring the effectiveness of the CLASS program services and the individual's progress toward achieving the outcomes identified;
  • revising the IPC, as appropriate;
  • accessing non-CLASS program services;
  • crisis resolution; and
  • advocating for the individual's needs.

Case Management Agency (CMA) — Contracted agency that provides case management services to the individual.

Catchment Area — A geographic area composed of multiple Texas counties.

Consumer Directed Services (CDS) Option — A service delivery option in which an individual/LAR employs and retains service providers and directs the delivery of program services.

Consumer Directed Service Agency (CDSA) — The name of the entity that provided financial management services to the individual/LAR who serve as the employer of their service providers. The entity is now called Financial Management Services Agency (FMSA).

Continued Family Service (CFS) Agency — Agency that provides services to an individual age 18 or older who resides with a support family, which allows the individual to reside successfully in a community setting by training the individual to acquire, retain and improve self-help, socialization and daily living skills or assisting the individual with ADL. The individual must be receiving support family services immediately before receiving continued family services. A CFS agency must maintain licensure as a Child-Placing Agency through the Texas Department of Family and Protective Services (DFPS).

Consumer Rights and Services (CRS) — A division within the Department of Aging and Disability Services (DADS) that receives and processes complaints from individuals, family members, providers and the general public about the care, treatment or services provided to an individual.

 

# A C D E F H I L M N P R S T U

 

Denial — An action taken by DADS that:

  • denies an individual's request for enrollment into the CLASS program;
  • disallows a CLASS program service requested on an IPC that was not authorized on the prior IPC; or
  • disallows a portion of the amount or level of a CLASS program service requested on an IPC that was not authorized on the prior IPC.

Department of Aging and Disability Services (DADS) — Texas state agency that provides long-term services and supports to older people and individuals with physical, intellectual and developmental disabilities. DADS also regulates providers of long-term services and supports, and administers the state's guardianship program.

Department of Assistive and Rehabilitative Services (DARS) — Texas state agency that administers programs that ensure Texas is a state where people with disabilities, and children who have developmental delays, enjoy the same opportunities as other Texans to live independent and productive lives.

Department of Family and Protective Services (DFPS) — Texas state agency that protects children, the elderly and people with disabilities from abuse, neglect and exploitation by involving clients, families and communities.

Department of State Health Services (DSHS) — Texas state agency that promotes optimal health for individuals and communities while providing effective health, mental health and substance abuse services to Texans.

Direct Services — CLASS program services other than case management, financial management services, support consultation or transition assistance services.

Direct Service Agency (DSA) — A program provider that is a licensed Home and Community Supports Service Agency (HCSSA) that contracts with DADS to provide direct services to the individual.

Durable Medical Equipment (DME) — Purchased or rented items such as hospital beds, iron lungs, oxygen equipment, seat lift equipment, wheelchairs and other medically necessary equipment prescribed by a health care provider to be used in an individual's home. These items must be reusable. These items may require the Certificate of Medical Necessity form required by Medicare and Medicaid to use certain durable medical equipment prescribed by a health care provider.

 

# A C D E F H I L M N P R S T U

 

Exploitation — An act of depriving, defrauding or otherwise obtaining the personal property of an individual by taking advantage of an individual's disability or impairment.

 

# A C D E F H I L M N P R S T U

 

Fair Hearing — An administrative procedure that affords individuals the statutory right and opportunity to appeal adverse decisions/actions regarding program eligibility or termination, suspension or reduction of services by DADS.

Financial Management Services Agency (FMSA) — An entity that provides financial management services to the individual/LAR who serve as the employer of their service providers.

 

# A C D E F H I L M N P R S T U

 

Habilitation Attendant — A direct service provider who can be an employee of a DSA or a CDS employer who assists an individual to reside successfully in a community setting by training the individual to acquire, retain and improve self-help, socialization and daily living skills or assisting the individual with ADLs.

Health and Human Services Commission (HHSC) — Texas state agency that provides leadership and direction, and fosters the spirit of innovation needed to achieve an efficient and effective health and human services system for Texans. HHSC oversees the operations of the health and human services system, provides administrative oversight of Texas health and human services programs, and provides direct administration of some programs, which is composed of five agencies:

  • Health and Human Services Commission (HHSC)
  • Department of Aging and Disability Services (DADS)
  • Department of State Health Services (DSHS)
  • Department of Assistive and Rehabilitative Services (DARS)
  • Department of Family and Protective Services (DFPS)

 

# A C D E F H I L M N P R S T U

 

Individual — A person who is determined by DADS to be eligible for or who receives CLASS program services.

 

Individual Education Plan (IEP) — An individualized education program developed by the parents and educators for each child with a disability that is developed, reviewed and revised in a meeting in accordance with the Individuals with Disabilities Education Act. The IEP describes the goals the team sets for a child during the school year, as well as any special support needed to help achieve them.

Individual Plan of Care (IPC) — A written plan developed by an individual's service planning team that describes the type and amount of each CLASS program service to be provided to the individual, and services and supports to be provided to the individual through non-CLASS program resources including natural supports, medical services and educational services.

IPC Period — The effective period of an enrollment IPC and a renewal IPC as follows:

  • for an enrollment IPC, the period of time from the effective date of an enrollment IPC, until the first calendar day of the same month of the effective date in the following year; and
  • for a renewal IPC, a 12-month period of time starting on the effective date of a renewal IPC.

Individual Program Plan (IPP) — A written plan that describes the goals and objectives to be met by the provision of each CLASS program service on an individual's IPC that are supported by justifications, are measurable and have timelines.

Institutional Services — Medicaid-funded services provided in a nursing facility licensed in accordance with Texas Health and Safety Code, Chapter 242, or in an ICF/ID certified by DADS for a capacity of more than six people.

Intermediate Care Facility for Persons with Intellectual Disability (ICF/ID) — A public or private facility that provides health and habilitation services to individuals with intellectual disabilities or related conditions.

Interest List (IL) — A list of people who have contacted DADS and expressed an interest in receiving waiver services, but who have not applied for or been determined eligible for services.

 

# A C D E F H I L M N P R S T U

 

Legally Authorized Representative (LAR) — A person authorized by law to act on behalf of an individual, which may include a parent, guardian or managing conservator of a minor, or the guardian of an adult.

 

# A C D E F H I L M N P R S T U

 

Medicaid — A program administered by the federal Centers for Medicare and Medicaid Services (CMS), and funded jointly by the states and the federal government, that pays for health care to eligible groups of people.

Medicaid Eligible — A person who is financially eligible for Medicaid because the individual receives Supplemental Security Income (SSI) cash benefits or is determined by HHSC to be financially eligible for Medicaid.

Medicare — The federal health insurance program for people age 65 or older, certain younger people with disabilities and people with End-Stage Renal Disease.

Medicaid Eligibility Services Authorization Verification (MESAV) — The automated system used by DADS to notify providers of Medicaid eligibility and service authorizations.

Money Follows the Person (MFP) — A policy that allows residents of nursing facilities to enroll into certain Medicaid waiver programs without having to wait on a program interest list upon determination of program eligibility.

Mutually Exclusive — DADS waiver or Community Care for the Aged and Disabled (CCAD) services that an individual may not receive while enrolled in the CLASS program because services may be duplicative in addressing the individual's needs.

 

# A C D E F H I L M N P R S T U

 

Neglect — The failure to provide an individual the reasonable care required, including but not limited to:

  • food,
  • clothing,
  • shelter,
  • medical care,
  • personal hygiene, and
  • protection from harm.

Non-CLASS Services — Services that are not provided under CLASS waiver provisions of §1915(c) of the Social Security Act.

Notice — A written statement describing the intent of action the state will bring against an individual or the individual's LAR at least 10 days before the date of action.

Nursing Facility — A residential institution that primarily provides:

  • skilled nursing care and related services for residents who require medical or nursing care;
  • rehabilitation services for the rehabilitation of injured, disabled or sick people; or
  • health-related care and services, on a regular basis, to individuals who, because of their mental or physical condition, require care and services, above the level of room and board, which can be made available to them only through institutional facilities.

 

# A C D E F H I L M N P R S T U

 

Provider Agency — An entity that has a contract with DADS to deliver CLASS services. See DSA and CMA.

 

# A C D E F H I L M N P R S T U

 

Related Condition (RC) — A severe chronic disability attributed to a condition other than mental illness but found to be closely related to intellectual disability. The condition results in impairment of general intellectual functioning or adaptive behavior similar to that of people with intellectual disabilities and requires treatment or services similar to those required for people with intellectual disabilities. It is manifested before the person reaches age 22, is likely to continue indefinitely, and results in substantial functional limitations in at least three of the following areas of major life activity:

  • self care,
  • understanding and use of language,
  • learning,
  • mobility,
  • self-direction, and
  • capacity for independent living.

 

# A C D E F H I L M N P R S T U

 

Service Planning Team (SPT) — A planning team convened and facilitated by a CLASS program case manager consisting of:

  • individual/LAR,
  • case manager, and
  • DSA representative.

An SPT may also include:

  • other people as requested by the individual/LAR; and
  • a person selected by the DSA, with the approval of the individual or LAR, who is professionally qualified by certification or licensure and has special training and experience in the diagnosis and habilitation of people with the individual's related condition, or directly involved in the delivery of services and supports to the individual.

Support Family Service (SFS) Agency — Agency providing services to an individual under age 18 who resides with a support family that allows the individual to reside successfully in a community setting by supporting the individual to acquire, maintain and improve self-help, socialization and daily living skills or assisting the individual with ADLs. An SFS agency must maintain licensure as a Child-Placing Agency through DFPS.

Suspension — A temporary cessation of any waiver service without the loss of Medicaid or program eligibility.

 

# A C D E F H I L M N P R S T U

 

Transition Assistance Services (TAS) Agency — Agency that provides a one-time service to a Medicaid-eligible resident of a nursing facility located in Texas to assist the resident in moving from the nursing facility into the community.

Termination — A term used when an individual no longer meets the program’s eligibility criteria and services are ended.

Texas Health Steps-Comprehensive Care Program — Texas Health Steps is also known as the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) service, which is Medicaid's comprehensive preventive child health service (medical, dental and case management) for individuals from birth through age 20. Texas Health Steps is dedicated to:

  • expanding recipient awareness of existing medical, dental and case management services through outreach and informing efforts, and;
  • recruiting and retaining a qualified provider pool to assure the availability of comprehensive preventive medical, dental and case management services.

Texas Medicaid & Healthcare Partnership (TMHP) — A coalition of contractors headed by ACS State Healthcare LLC, which administers claims processing for Texas Medicaid and other state health-care programs for the state of Texas, under contract with HHSC.

 

# A C D E F H I L M N P R S T U

 

Utilization Review — A formal assessment of the medical necessity, efficiency or appropriateness of services and treatment plans on a prospective, concurrent or retrospective basis.