Appendices

Appendices Anonymous (not verified) Mon, 09/19/2016 - 14:50

Appendix I, Adaptive Aids

Appendix I, Adaptive Aids Anonymous (not verified) Mon, 09/19/2016 - 17:14
Body

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 Section 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

Appendix II, Minor Home Modification Services Anonymous (not verified) Mon, 09/19/2016 - 16:12
Body

Revision 17-1; Effective November 1, 2017

 

Home modifications are those services that assess the need to arrange for and provide modifications and/or improvements to the individual's living quarters to allow 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 additional information to 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 individual 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 individual'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 individual and how the MHM will meet those needs (for example, an individual who uses a wheelchair for mobility in his home and the community 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/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 with a cost of $1,000 or higher, 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 with a cost of $1,000 or higher, 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 telephone 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 an individual receiving CLASS program services is $10,000. This is a lifetime limit for an individual who receives CLASS program services. After reaching the lifetime maximum cost of $10,000, an individual 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 individual, such as carpeting (except to allow independent mobility for persons using crutches, wheelchairs, three-wheel scooters, and other aids which offer increased personal mobility), roof repair, central air conditioning, etc. 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 in accordance with Chapter 401 of the Texas Occupations Code.
  • Licensed Psychological Associate (PSA) — A person licensed as a psychological associate in accordance with the Texas Occupations Code, Chapter 501.
  • Licensed Professional Counselor (LPC) — A person licensed as a professional counselor in accordance with the Texas Occupations Code, Chapter 503.
  • 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) — A person licensed as a physician in accordance with the Texas Occupations Code, Chapter 155.
  • 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.

Home modifications 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. Home Modifications
    1. floor leveling (only in residences owned by the individual and/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 individual, 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/work surface adjustments (OT, PT)
    14. cabinet development/adjustments (OT, PT)
  2. Specialized Accessibility/Safety Adaptations/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 and/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 and/or driveway to residence when existing surface condition is a safety hazard for the person with a disability (OT, PT)
    6. porch/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 (does not include home security systems), security door locks, fire safety approved window locks, security window screens and visual alert systems (for example, for individuals 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 individuals with behavior problems (OT, PT, MD, PSA, LPC)
    13. emergency back-up gas-powered 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 individuals 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 III, Mutually Exclusive Services

Appendix III, Mutually Exclusive Services Anonymous (not verified) Mon, 09/19/2016 - 18:06

Appendix IV, Dental Treatment

Appendix IV, Dental Treatment Anonymous (not verified) Mon, 09/19/2016 - 18:08
Body

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

Appendix V, ID/RC Processing, for additional information and detailed instructions for DSAs Anonymous (not verified) Mon, 09/19/2016 - 17:07
Body

Revision 18-1; Effective February 14, 2018

 

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, 2017):
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 VI, DADS Contract Management

Appendix VI, DADS Contract Management Anonymous (not verified) Mon, 09/19/2016 - 18:24

Appendix VII, HIV/AIDS in the Workplace

Appendix VII, HIV/AIDS in the Workplace Anonymous (not verified) Mon, 09/19/2016 - 18:29

Appendix VIII, Medicaid for the Elderly and People with Disabilities

Appendix VIII, Medicaid for the Elderly and People with Disabilities Anonymous (not verified) Mon, 09/19/2016 - 18:27

Appendix IX, List of Excluded Individuals and Entities (LEIE)

Appendix IX, List of Excluded Individuals and Entities (LEIE) Anonymous (not verified) Mon, 09/19/2016 - 18:33

Appendix X, IPP Service Summary/IPP Service Review Due Dates Chart

Appendix X, IPP Service Summary/IPP Service Review Due Dates Chart Anonymous (not verified) Mon, 09/19/2016 - 16:36
Body

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

Appendix XI, Retired Information Letters Anonymous (not verified) Mon, 09/19/2016 - 18:39
Body

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 XII, Advance Directives

Appendix XII, Advance Directives Anonymous (not verified) Mon, 09/19/2016 - 18:40

Appendix XIII, Critical Incident Reporting

Appendix XIII, Critical Incident Reporting acarreras Tue, 12/18/2018 - 13:22

Appendix XIV, Solicitation Prohibition

Appendix XIV, Solicitation Prohibition Anonymous (not verified) Mon, 04/29/2019 - 06:59

Appendix XV, Abuse, Neglect, and Exploitation Training and Competency Test

Appendix XV, Abuse, Neglect, and Exploitation Training and Competency Test acarreras Mon, 06/03/2019 - 10:39
Body

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

Appendix XVI, Value-added Services Anonymous (not verified) Fri, 11/22/2019 - 13:47
Body

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”

Appendix XVII, Definition of the Term “Relative” acarreras Wed, 01/22/2020 - 12:47
Body

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

  1st Degree 2nd Degree 3rd Degree 4th Degree
Person child
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

  1st Degree 2nd Degree
Person spouse
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

Appendix XVIII, CLASS Program Provider Computer-Based Training and Competency Test acarreras Wed, 05/27/2020 - 10:16
Body

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%.