Revision 22-3; Effective Dc. 1, 2022

Community First Choice (CFC) is a group of services delivered under the authority of Section 1915(k) of the Social Security Act. CFC is authorized by federal regulations governing home and community-based services. The settings that CFC is delivered must be compliant with Title 42 Code of Federal Regulations (CFR) Section 441.301(c)(4) and Section 441.710. Permissible home and community-based settings include member homes, apartment buildings and non-residential settings. Community-based settings exclude:

• nursing facilities;
• hospitals providing long-term care services;
• inpatient psychiatric facilities;
• intermediate care facilities for individuals with an intellectual disability or related conditions (ICF/IID); and
• settings on the grounds of, adjacent to, or with the characteristics of, an institution.

Members served in provider owned and controlled residential settings are excluded from CFC because their provider rate includes payment for the provision of CFC-like services. To provide CFC is duplicative.

In addition, assessment for CFC services and the development of a member's service plan must be person centered, as required by 42 CFR Section 441.535 and Section 441.540. STAR Kids managed care organizations may not require CFC providers to obtain a denial or explanation of benefits from a member's primary insurance before seeking reimbursement for CFC services.

4110 Community First Choice Eligibility

Revision 22-3; Effective Dc. 1, 2022

Eligibility for Community First Choice (CFC) requires a STAR Kids member to:

• be Medicaid eligible;
• meet the level of care provided in a hospital, nursing facility (NF), intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID), or an institution for mental disease (IMD); and
• have an assessed functional need for CFC services.

All STAR Kids members are Medicaid eligible. Members whose Medicaid eligibility is established for the Youth Empowerment Services (YES) or Medically Dependent Children Program (MDCP) waivers are eligible for CFC services, per Section 1902(a)(10)(A)(ii)(VI) of the Social Security Act, as long as they receive at least one waiver service per month or monthly monitoring if waiver services are furnished on a less than monthly basis, as these members meet an IMD and an NF LOC, respectively. Members whose eligibility is established as Medical Assistance Only (MAO) Medicaid must receive at least one waiver service per month to maintain eligibility. 

A member may not be authorized to receive both personal care services (PCS) and CFC services at the same time. Members eligible for CFC will receive CFC-PCS and habilitation (CFC-HAB) in lieu of PCS.

Members who receive services through the following 1915(c) waiver programs receive CFC services through their fee-for-service waiver provider and do not receive CFC through managed care:

• Community Living Assistance and Support Services (CLASS)
• Deaf Blind with Multiple Disabilities (DBMD)
• Home and Community-based Services (HCS)
• Texas Home Living (TxHmL)
   

4111 Determining Institutional Level of Care

Revision 22-3; Effective Dc. 1, 2022

Nursing Facility (NF) Level of Care

For STAR Kids members, the STAR Kids Screening and Assessment Instrument (SK-SAI) contains the elements necessary for Texas Medicaid & Healthcare Partnership (TMHP) to determine, on behalf of the Texas Health and Human Services Commission (HHSC), if a member meets medical necessity (MN) for the level of care (LOC) provided in a hospital or NF. Questions within the SK-SAI which identify a need for Community First Choice (CFC) personal assistance services (PAS)/habilitation (HAB) services are within the Core  and Nursing Care Assessment (NCAM) modules of the SK-SAI. Once the SK-SAI is completed, if the STAR Kids managed care organization (MCO) seeks a determination of MN for CFC, the MCO must obtain the member's physician's signature on Form 2601, Physician Certification, certifying the member requires NF services or alternative community based services under the supervision of a physician.

Find information about the medical necessity determination process for CFC in 3110, Assessment of Medical Necessity for Community First Choice.

Intermediate Care Facility for Individuals with an Intellectual Disability or Related Condition (ICF/IID) Level of Care

For STAR Kids applicants and members, the MCO must contact the Local Intellectual and Developmental Disability Authority (LIDDA) to conduct an assessment to determine whether a STAR Kids applicant or member meets the LOC provided by an ICF/IID. As part of the Intellectual Disability or Related Condition (ID/RC) assessment, the LIDDA must collect information necessary to complete a Determination of Intellectual Disability (DID), if a STAR Kids applicant or member does not have one on file. The LIDDA must submit the ID/RC information to HHSC for a determination of ICF-IID LOC. HHSC notifies the STAR Kids applicant or member's MCO of an ICF/IID LOC denial. The LIDDA notifies the STAR Kids applicant or member’s MCO of an ICF/IDD LOC approval. If a STAR Kids applicant or member meets the LOC provided in an ICF/IID, the MCO completes the CFC functional assessment if the applicant or member requests CFC services.

Institution for Mental Disease Level of Care

For STAR Kids applicants and members, the MCO may contact a comprehensive provider of mental health rehabilitative services or a local mental health authority (LMHA) to conduct the Children and Adolescent Needs and Strengths (CANS) or Adult Needs and Strengths Assessment (ANSA) and a licensed practitioner determines whether the STAR Kids applicant or member meets an institution of mental disease (IMD) LOC. If the STAR Kids applicant or member needs the LOC provided in an IMD, or receives services through the Youth Empowerment Services program, the MCO conducts the CFC functional assessment if the member requests CFC services.

4120 Community First Choice Services

Revision 22-2; Effective September 1, 2022

Community First Choice (CFC) services include personal care services (PCS), habilitation (HAB), emergency response services (ERS) and support management.

4121 Personal Care Services Provided Through Community First Choice

Revision 22-3; Effective Dec. 1, 2022

Community First Choice (CFC) includes personal care services (PCS) which provide assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs) through hands-on assistance, supervision or cueing. Assistance is provided to a member in performing ADLs and IADLs based on a person-centered service plan. Services include:

• Non-skilled assistance with the performance of ADLs and IADLs
• Household chores necessary to maintain the home in a clean, sanitary and safe environment
• Escort services, which consist of accompanying, but not transporting, and helping a member access services or activities in the community 
• Assistance with health-related tasks per state law, health-related tasks include: 
  • tasks delegated by a registered nurse (RN);
  • health maintenance activities; and 
  • extension of therapy which is an activity that a speech therapist, physical therapist or occupational therapist instructs the member to do as follow up to therapy sessions. If appropriate, the member's attendant can help the member accomplish such activities with supervision, cueing and hands-on assistance.

In the Consumer Directed Services (CDS) service delivery option, the member or legally authorized representative determines health-related tasks without a nurse assessment, per Section 531.051(e) of the Texas Government Code and Section 225.4 of the Texas Administrative Code.

CFC services include personal care services (PCS) to help with ADLs, IADLs, and health-related tasks through hands-on assistance, supervision or cueing, including nurse-delegated tasks.  Members who qualify for a CFC LOC must have PCS billed as CFC-PCS. Members may not be authorized for PCS and CFC-PCS at the same time. Information used to build a plan of care  may be found in the STAR Kids Screening and Assessment Instrument (SK-SAI) Sections I-L. The member may receive CFC-PCS and CFC-HAB only if the member meets one of the CFC LOC criteria.

4122 Community First Choice Habilitation

Revision 22-3; Effective Dec. 1, 2022

Community First Choice (CFC) habilitation helps members with acquisition, maintenance and enhancement of skills necessary for the member to accomplish activities of daily living (ADLS), instrumental activities of daily living (IADLs) and health-related tasks. This service is given to allow a member to live successfully in a community setting by assisting the member to get, keep and improve self-help, socialization, and daily living skills or helping with and training the member on ADLs and IADLs. Personal care services may be a component of CFC habilitation for some members. CFC habilitation services include training, which is interacting face-to-face with a member to train the member in activities 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 members to accomplish ADLs, IADLs and health-related tasks; and
• self-administration of medication.

Find information used to build a plan of care for CFC habilitation in the STAR Kids Screening and Assessment Instrument (SK-SAI) Section M. This section of the SK-SAI should only be administered after the assessor or service coordinator explains the CFC benefit and the member wishes to be assessed for habilitation.

4123 Community First Choice Emergency Response Service

Revision 22-2; Effective September 1, 2022

Community First Choice (CFC) emergency response services (ERS) are designed to assist individuals who live alone, are alone for large parts of the day, or have no regular caregiver for extended periods of time and who would otherwise require extensive routine supervision. This service connects a member to an ERS provider who notifies local authorities, like paramedics or a fire department, of a member's emergency. This service is not routinely authorized for members who are minors.

ERS provides backup systems and supports to ensure continuity of services and supports. Reimbursement for backup systems and supports is limited to electronic devices to ensure continuity of services and supports. A member must be cognitively able to recognize an emergency situation and be able to recognize the need to use CFC-ERS for CFC-ERS to be authorized.

The need for ERS is assessed using the STAR Kids Screening and Assessment Instrument (SK-SAI), Section Q.

4124 Community First Choice Support Management

Revision 22-2; Effective September 1, 2022

Community First Choice (CFC) support management provides voluntary training on how to select, manage and dismiss attendants. Support management is available to any member receiving CFC services, regardless of the selected service delivery model.

Need for support management is assessed using the STAR Kids Screening and Assessment Instrument, Section Q.

4130 Community First Choice Assessment and Authorization

Revision 22-3; Effective Dec. 1, 2022

4131 Assessment for a Nursing Facility Level of Care

Revision 22-3; Effective Dec. 1, 2022

Establish nursing facility level of care (LOC) for members seeking Community First Choice (CFC) services using the STAR Kids Screening and Assessment Instrument (SK-SAI). The managed care organization (MCO) must complete all "MN required" fields, as specified in Appendix I, MCO Business Rules for SK-SAI and SK-ISP, particularly items contained in the Nursing Care Assessment Module (NCAM). These items will be used by a Texas Medicaid & Healthcare Partnership (TMHP) nurse to evaluate the member's eligibility for NF services according to the Texas Administrative Code Section 554.101(80) definition of “medical necessity.”

The MCO must indicate yes in Field Q6a to notify TMHP that an MN determination is required. TMHP's determination will be communicated to the MCO on the substantive response file, as specified in Appendix I.

If TMHP determines that the member does not meet MN, the member is not eligible to receive CFC through the nursing facility LOC. Note: This does not preclude the member or MCO from seeking determination of a different institutional LOC through the LIDDA or LMHA.

If TMHP determines that that the member meets MN and the functional assessment conducted by the MCO indicates a need for CFC services, the member is eligible to receive CFC through the nursing facility LOC.

4132 Reassessment for a Nursing Facility Level of Care

Revision 22-2; Effective September 1, 2022

To ensure continued eligibility for Community First Choice (CFC) services, the managed care organization (MCO) administers the entire STAR Kids Screening and Assessment Instrument (SK-SAI), including appropriate modules, no earlier than 90 Days before or no later than 30 days prior to the expiration of the member’s current individual service plan (ISP) on file. The MCO must indicate yes in Field Q6a to notify Texas Medicaid & Healthcare Partnership (TMHP) that a medical necessity (MN) determination is required. Form 2601, Physician Certification, is not required for annual MN reassessments if the member's file contains the form for a previous assessment. The MCO must ensure that the reassessment is timed to prevent any lapse in service authorization.

4133 Assessment for an Intermediate Care Facility Level of Care

Revision 22-3; Effective Dec. 1, 2022

Described in Section 4111, Determining Institutional Level of Care, if the managed care organization (MCO) knows or believes a member has an intellectual disability or related condition (ID/RC), the MCO refers the member to the Local Intellectual and Developmental Disability Authority (LIDDA). The MCO must authorize personal care services (PCS), as appropriate, while level of care (LOC) determination is pending. 

The LIDDA and the MCO communicate during the assessment process through a Secure File Transfer Protocol (SFTP) site, updating the file as the member moves through the assessment process. The MCO initiates a referral to the LIDDA by adding a referred member to the spreadsheet. The MCO must provide the member's named service coordinator’s contact information to assist in coordinating assessment activities. Following completion of the determination of intellectual disability (DID) and ID/RC assessment, the LIDDA submits the assessment for a determination of LOC to the state. The Texas Health and Human Services Commission (HHSC) informs both the LIDDA and MCO of the determination. If a member is determined to not meet the level of care provided in an intermediate care facility for individuals with an intellectual disability or related condition (ICF/IID), the MCO is responsible for notifying the member through the established denial process. HHSC attends the fair hearing if one is requested.

If a member meets an ICF/IID level of care, the MCO follows the process outlined in Section 4140, Functional Assessment for Community First Choice Services, to determine the member's service plan. When the member selects a service provider, the MCO updates the SFTP site noting the member's selected provider. If a member declines or discontinues Community First Choice services, the MCO must update the SFTP site noting the date the member declined or discontinued services.

4134 Reassessment for an Intermediate Care Facility Level of Care

Revision 22-3; Effective Dec. 1, 2022

Ninety days before the expiration of the member's level of care assessment, the Local Intellectual and Development Disability Authority (LIDDA) updates the Secure File Transfer Protocol (SFTP) site requesting the managed care organization (MCO) confirm the member requires a reassessment of an intermediate care facility for individuals with an intellectual disability or related condition (ICF/IID) level of care. If a member is receiving Community First Choice (CFC) services, the MCO indicates the member requires a reassessment. If the member declined or discontinued CFC services, the MCO indicates the member does not require a reassessment. The LIDDA and the MCO follow the processes outlined in Section 4132, Assessment for an ICF/IID Level of Care, for all reassessments.

If a member continues to meet an ICF/IID level of care, the MCO follows the process outlined in Section 4140, Functional Assessment for CFC Services, to determine the member's service plan. When the member selects a service provider, the MCO updates the SFTP site noting the member's selected provider. If a member declines or discontinues CFC services, the MCO must update the SFTP site noting the date the member declined or discontinued services.

4135 Assessment for an Institution Providing Psychiatric Services Level of Care

Revision 22-2; Effective September 1, 2022

Described in 4111, Determining Institutional Level of Care, if the managed care organization (MCO) knows or believes a member has serious emotional disturbance (SED) or serious and persistent mental illness (SPMI), the MCO refers the member to a comprehensive provider agency that can deliver mental health targeted case management and mental health rehabilitative services. This provider conducts the Child and Adolescent Needs or Strengths (CANS) or Adult Needs and Strengths Assessment (ANSA), depending on the member's age. Based on an algorithm, the assessment determines the member's level of care (LOC). A member may be deviated into a higher or lower LOC, based on clinical judgement and member preference. A licensed practitioner of the healing arts (LPHA) must review the member’s diagnosis at least annually. Mental health rehabilitative services are reassessed more frequently than the LOC for Community First Choice (CFC) services. For the purposes of eligibility for CFC services, a member's CANS or ANSA is valid for 12 months. The MCO must authorize personal care services (PCS), as appropriate, while LOC determination is pending.

Members enrolled in the Youth Empowerment Services (YES) waiver meet an institution for mental disease level of care and do not require an additional assessment of LOC to receive CFC services. These members may be assessed by their MCO for functional eligibility for CFC services at any time while enrolled in YES. 

4136 Reassessment for an Institution for Mental Disease Level of Care

Revision 22-2; Effective September 1, 2022

Assessment of an institution for mental disease (IMD) level of care (LOC) must be reassessed annually for continued eligibility for Community First Choice (CFC) services. Sixty days prior to the expiration of the member's CFC service plan, the managed care organization (MCO) must refer the member to the local mental health authority (LMHA) or to a comprehensive provider for mental health rehabilitative services. This provider conducts the Child and Adolescent Needs or Strengths (CANS) or Adult Needs and Strengths Assessment (ANSA), which must be reviewed by a licensed practitioner to determine if the member continues to meet a psychiatric institutional LOC. If the member continues to meet this LOC, the MCO conducts the CFC functional assessment.

If the member does not meet an IMD level of care, the MCO must conduct the STAR Kids Screening and Assessment Instrument (SK-SAI) to determine if the member meets medical necessity for a nursing facility LOC. If the MCO believes the member will not meet medical necessity and does not have an intellectual or developmental disability, the MCO must notify the member or their representative of the denial for CFC services. The member may be eligible for personal care services (PCS), if functionally necessary.

4140 Functional Assessment for Community First Choice Services

Revision 22-3; Effective Dec. 1, 2022

Functional need for Community First Choice (CFC) services is established by Sections I, J, K, L and M of the STAR Kids Screening and Assessment Instrument (SK-SAI). These sections contain assessment questions for the personal care services (CFC-PCS) and habilitation services (CFC-HAB) available through CFC. Section M should only be completed if the member is specifically seeking CFC services. Based on the assessment, the service coordinator develops a recommended service plan for the delivery of CFC services. The service coordinator works with the member or their representative to locate an appropriate provider and sends an authorization to the selected provider.

If a member approved for the nursing facility (NF) level of care (LOC) does not agree to the CFC service plan, they may file an appeal with the MCO.

If the STAR Kids applicant or member does not agree to the CFC service plan or refuses CFC services for the intermediate care facility for individuals with intellectual disability or related condition (ICF/IID) LOC or the institutions of mental disease (IMD) LOC, the MCO must notify the local intellectual or developmental disability authority (LIDDA) or local mental health authority (LMHA) within 10 business days of the member ending CFC services.

4141 Reassessment of Functional Need for Community First Choice

Revision 22-2; Effective September 1, 2022

The need for and the amount and duration of Community First Choice services must be reassessed every 12 months, or when requested by the member or as needed due to a change in the member's health condition or living situation.

Revision 22-3; Effective Dec. 1, 2022

Personal care services (PCS) is a benefit under the Early and Periodic Screening, Diagnosis, and Treatment Comprehensive Care Program, known in Texas as the Texas Health Steps Comprehensive Care Program (THSteps-CCP). PCS is available to STAR Kids members from birth through 20. PCS is considered medically necessary when a member requires help with activities of daily living (ADLs), instrumental activities of daily living (IADLs), or health maintenance activities (HMAs) because of physical, cognitive, or behavioral limitations related to the member's disability or chronic health condition. The member's disability or chronic health condition must be substantiated by a practitioner statement of need (PSON). STAR Kids managed care organizations (MCO) may not require PCS providers to obtain a denial or explanation of benefits from a member's primary insurance before seeking reimbursement for PCS.

As defined by law, the scope of ADLs, IADLs, and HMAs includes a range of activities that healthy, nondisabled adults can perform for themselves. Developing children gradually and sequentially acquire the ability to perform ADLs and IADLs for themselves. PCS does not include ADL, IADL or HMA activities that a typically developing child of the same chronological age would not be able to safely and independently perform without adult supervision. As required by law, a member's responsible adult must perform ADLs, IADLs and HMAs on behalf of the individual to the extent that the need to do so would exist in a typically developing child of the same chronological age. Medicaid PCS benefits are limited to situations where the need for assistance to perform the ADLs, IADLs and HMAs is caused by the member's physical, cognitive, or behavioral limitation related to the member’s disability or chronic health condition. PCS includes direct intervention to help the individual perform a task or indirect intervention by cueing the individual to perform a task.

Individuals must have a medical or cognitive need for specific tasks. PCS is medically necessary only when an individual has a physical, cognitive, or behavioral limitation related to the individual’s disability or chronic health condition that affects the individual’s ability to accomplish ADLs, IADLs or HMAs.

PCS includes:

• Assistance with ADLs and IADLs
• Nurse-delegated tasks and HMAs within the scope of PCS, as permitted by program policy and 22 Texas Administrative Code Chapter 225 (relating to RN Delegation to Unlicensed Personnel and Tasks not Requiring Delegation in Independent Living Environments for Clients with Stable and Predictable Conditions)
• Hands-on assistance, cueing, redirecting, or intervening to accomplish the approved PCS task

The amount and duration of PCS is determined by the MCO and must take the following into account:

• Whether the member has a physical, cognitive or behavioral limitation related to a disability or chronic health condition that affects their ability to accomplish ADLs or IADLs
• The member's caregiver's need to sleep, work, attend school and meet their own medical needs
• The member's caregiver's legal obligation to care for, support, and meet the medical, educational and psychosocial needs of other members of the household
• The member's caregiver's physical ability to perform PCS
• Whether requiring the member's caregiver to perform PCS will put the member's health or safety in jeopardy
• The time periods when PCS tasks are required by the member, as they occur over the course of a 24-hour day and a seven-day week
• Whether or not the need to assist the family in performing PCS on behalf of the member is related to a medical, cognitive or behavioral condition that results in a level of functional ability below what is expected of a typically developing child of the same chronological age
• Whether services are needed based on the physician’s statement of need and the assessment for personal care described in Section 4210 that follows

PCS may be authorized to support a member's primary caregiver(s) but may not be authorized to supplant a member's natural support, nor to provide a member's total care. PCS may be authorized in an individual or group setting including, but is not limited to the:

• member's home;
• home of the primary or other caregiver;
• member's school;
• member's day care facility; or
• community setting in which the member is located.

The MCO must not reimburse PCS that duplicates services that are the legal responsibility of the school district. The school district, through the School Health and Related Services (SHARS) program, must meet the member's personal care needs while the member is at school. However, if those needs cannot be met by SHARS or the school district, documentation must be submitted to the MCO with documentation of medical necessity.

PCS may not be authorized in a hospital, nursing facility, institution providing psychiatric care, or an intermediate care facility for individuals with intellectual or developmental disabilities (ICF/IID).

PCS may not be used as respite, child care, or to restrain a member. PCS may be authorized in a group setting.

A member may not be authorized to receive both PCS and Community First Choice (CFC) services at the same time.

Members who receive services through the following 1915(c) waiver programs receive CFC services through their waiver program and are not eligible to receive PCS through the MCO:

• Community Living Assistance and Support Services (CLASS);
• Deaf Blind with Multiple Disabilities (DBMD);
• Home and Community-based Services (HCS); and
• Texas Home Living (TxHmL) Program.

4210 Assessment for Personal Care Services

Revision 22-2; Effective September 1, 2022

Sections I, J, K and L of the STAR Kids Screening and Assessment Instrument (SK-SAI) contain assessment questions for personal care services (PCS). Managed care organizations (MCOs) must have a mechanism in place to assist service coordinators in recommending a number of attendant hours. Based on the assessment, the service coordinator develops a recommended service plan for the delivery of PCS. The service coordinator works with the member or their representative to locate an appropriate provider and sends an authorization to the selected provider.

4211 Reassessment for Personal Care Services

Revision 22-2; Effective September 1, 2022

The need for and the amount and duration of personal care services (PCS) must be reassessed every 12 months, or when requested due to a change in the member's health or living condition. The managed care organization must obtain a new practitioner statement of need (PSON) to substantiate the member's continued need for PCS upon each annual reassessment.

4220 Personal Care Services Providers

Revision 22-2; Effective September 1, 2022

Personal care services (PCS) must be provided by an individual who:

• is 18 years of age or older;
• is an attendant who:
  • is an employee of a provider organization licensed as a Home and Community Support Services Agency (HCSSA) or organizations licensed to provide home health services or personal assistance services; or
  • is employed by the member or their legally authorized representative (LAR) through the Consumer Directed Services (CDS) option.

• has demonstrated the competence necessary, when competence cannot be demonstrated through education and experience, to perform the personal assistance tasks assigned by the HCSSA or by the member or the member's responsible adult or LAR acting as employer through the CDS option.
• is not the responsible adult of the member if the member is under the age of 18; and
• is not the spouse of the member.

Revision 22-3; Effective Dec. 1, 2022

Medicaid managed care organizations (MCOs) must follow all federal and state laws, rules and the provisions of the Texas Medicaid Provider Procedures Manual (TMPPM) and their contracts regarding Private Duty Nursing (PDN) services.

PDN services are a Texas Medicaid Texas Health Steps-Comprehensive Care Program (THSteps-CCP) benefit for STAR Kids members. PDN services are nursing services, described by the Texas Nursing Practice Act and its implementing regulations, for clients who meet the medical necessity criteria and who require individualized, continuous, skilled care beyond the level of skilled nursing (SN) visits normally authorized under Texas Medicaid Home Health SN and Home Health Aide (HHA) services.

PDN is a THSteps-CCP benefit per the Code of Federal Regulations, Title 42, Section 440.80, relating to PDN services, and Section 440.40(b), relating to Early Periodic Screening, Diagnostic and Treatment (EPSDT) services. THSteps-CCP is an expansion of the EPSDT service mandated by the Omnibus Budget Reconciliation Act (OBRA) of 1989, which requires all states to provide all medically necessary treatment for correction or amelioration of physical or mental illnesses and conditions to THSteps eligible clients when federal financial participation (FFP) is available, even if the services are not covered under the Medicaid state plan.

MCOs must follow all EPSDT requirements, including the provision of PDN services, for STAR Kids members.

State rules governing PDN are found at Texas Administrative Code (TAC) Title 1, Part 15, Chapter 363, Subchapter C. These rules and related policies, including rules and policy related to past authorization, apply to HHSC or its designees, which include MCOs (see 1 TAC Section 363.301(c), Section 363.303(6), and Section 363.311(b)). MCOs are must follow all policies governing PDN services in the TAC, as well as the latest edition of the TMPPM. Find Texas Medicaid’s THSteps-CCP PDN policy in Section 4 of the TMPPM’s Home Health and Private Duty Nursing Services Handbook. Find more Information about the THSteps-CCP Program in Section 2 of the TMPPM’s Children’s Services Handbook.

These rules and TMPPM policy provisions are the result of the final settlement agreement in the Alberto N., Et. Al. v. Albert Hawkins, Et. Al. lawsuit.

Because PDN is a Texas Medicaid THSteps-CCP service, the rules and related policies cited above apply directly to the STAR Kids program. See 8.1.2 Covered Services of Attachment B-1 of the STAR Kids Contract. MCOs must ensure that if their internal policy and procedure manuals contain language and guidance for processing PDN service requests, these documents are updated to align with all federal and state laws and rules, as well as the Texas Medicaid medical policy guidance available in the latest version of the TMPPM. See 7.02 MCO responsibility for compliance with laws and regulations of Attachment A of the STAR Kids Contract.

4310 Private Duty Nursing and Prescribed Pediatric Extended Care Center Services

Revision 20-2; Effective September 1, 2020

Private duty nursing (PDN) services and nursing services provided through a Prescribed Pediatric Extended Care Center (PPECC), as described in Section 4400 that follows, are considered to be an equivalent level of nursing care. An individual who qualifies for PDN will qualify for PPECC.

An individual has a choice of PDN, PPECC, or a combination of both PDN and PPECC for ongoing skilled nursing. Members must be informed of their service options for ongoing skilled nursing (PDN or PPECC) when PPECC services are available in the service delivery area. A member may receive both PDN and PPECC on the same day, but not at the same time (e.g., PDN may be provided before or after PPECC services are provided). The combined total hours between PDN and PPECC services is not anticipated to increase unless there is a change in the individual's medical condition or the authorized hours are not commensurate with the individual's medical needs. Per §363.209 (c)(3), PPECC services are intended to be a one-to-one replacement of PDN hours unless additional hours are medically necessary.

Because the total number of approved skilled nursing hours do not decrease, the Texas Health and Human Services Commission (HHSC) views a shift from PDN to PPECC as a provider change, and not an adverse action. The fee-for-service Nursing Addendum to the Plan of Care for PPECCs and PDN includes updated individual acknowledgements, including an acknowledgement that PDN hours may decrease if shifting the hours to the PPECC, or vice versa.

Achieving a one-to-one replacement of existing PDN hours with PPECC (or vice versa) to prevent service duplication will require an examination of authorizations for both PDN and PPECC services, including a review of the 24-hour flow sheet for nursing care. For example, when an individual with PDN decides to shift hours to a PPECC, then the PDN authorized hours will be decreased by the amount of hours shifted to a PPECC, unless there is a change in the individual’s medical condition requiring additional hours, or the authorized hours are not commensurate with the individual's medical needs. The PDN provider would be notified by the managed care organization of the revised (decreased) authorized hours. The PDN provider may submit a revision request with documentation to justify medical necessity for any additional hours requested. The PPECC and PDN providers are expected to coordinate on the respective plan of care for the individual. The service coordinator is expected to play a role in ensuring the coordination between PPECC and PDN service providers and authorized services.

Revision 22-3; Effective Dec. 1, 2022

Prescribed Pediatric Extended Care Center (PPECC) services is a benefit of the Texas Health Steps Comprehensive Care Program (THSteps-CCP). It is for STAR Kids members who meet the following medical necessity criteria for admission:

• eligible for THSteps-CCP;
• 20 years or younger
• have an acute or chronic condition that requires ongoing skilled nursing care and supervision, skillful observations, judgments and therapeutic interventions all or part of the day to correct or ameliorate health status;
• considered to be a medically dependent or technologically dependent member;
• stable for outpatient medical services, and does not present a significant risk to other individuals or personnel at the PPECC;
• requires ongoing and frequent skilled interventions to maintain or ameliorate health status, and delayed skilled intervention is expected to result in:
  • deterioration of a chronic condition;
  • loss of function;
  • imminent risk to health status due to medical fragility; or
  • risk of death;
• has a prescription for PPECC services signed and dated by an ordering physician who personally examined the member within 30 calendar days before admission and reviewed all appropriate medical records;
• has consent for the member's admission to the PPECC signed and dated by the member or the member's responsible adult. Admission must be voluntary and based on the preference for PPECC services in place of private duty nursing (PDN) by the member or member's responsible adult in both managed care and non-managed care service delivery systems; and
• lives with the responsible adult and not in any 24-hour inpatient facility, including a general acute hospital, skilled nursing facility (SNF), intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID) or special care facility.

PPECC services require prior authorization and are intended as an alternative to PDN. Members who receive PDN or qualify for PDN also qualify for PPECC services. However, an admission authorized under this section is not intended to supplant the right of a member to access PDN, personal care services (PCS), home health skilled nursing (HHSN), home health aide (HHA), and therapies (physical therapy, occupational therapy, speech therapy), as well as respiratory therapy and early childhood Intervention services rendered in the member's residence when medically necessary.

Note: PPECC services may be billed on the same day as PDN, PCS, HHSN and HHA, but must not be billed for the same span of time a member receives these other services.

A member who is eligible may receive both PDN and PPECC services. PPECC benefits include the following services:

• The development, implementation and monitoring of a comprehensive plan of care that:
  • is provided to a medically dependent or technologically dependent member;
  • is developed in conjunction with the member’s caregiver(s), ordering physician and interdisciplinary team;
  • specifies the services needed to address the medical, nursing, psychosocial, therapeutic, dietary, functional, and developmental needs of the member and the training needs of the member’s caregiver(s);
  • specifies if transportation to and from the PPECC is needed; and
  • is revised for each authorization of services, or more frequently as the ordering physician deems necessary.
• Direct skilled nursing care and caregiver training and education intended to:
  • optimize the member’s health status and outcomes; and
  • promote and support family-centered, community-based care as a component of an array of service options by:
    • preventing prolonged or frequent hospitalizations or institutionalization;
    • providing cost-effective, quality care in the most appropriate environment; and
    • providing training and education of caregivers;
• nutritional counseling and dietary services as specified in a member’s plan of care;
• help with activities of daily living while the member is in the PPECC;
• psychosocial and functional development services; and
• transportation services to and from a PPECC.
  • Transportation must be provided by a PPECC when a member has a stated need or a prescription for transportation to the PPECC.
  • When a PPECC provides transportation to a member, a nurse employed by the PPECC must be on board the transport vehicle.
  • The member must be able to utilize transportation services offered by the PPECC with the help of a PPECC nurse to and from the PPECC, rather than a non-emergency ambulance.
  • Transportation is billed separately by the PPECC when used by a member.
  • A non-emergency ambulance may not be used for transport to and from a PPECC.

Note: A separate authorization is not required for transportation to a PPECC. A member or LAR may decline PPECC transportation services.

PPECC services do not include services that are mainly respite care or child care, or that do not directly relate to the member’s medical needs or disability, nor for services that are the primary responsibility of a local school district. PPECC services also do not include:

• baby food or formula;
• services to members that are related to the PPECC owner by blood, marriage or adoption; and
• services covered separately by Texas Medicaid, such as;
  • therapies;
  • durable medical equipment; or
  • individualized comprehensive case management beyond that is required for service coordination.

Find more information about PPECC services in the STAR Kids Managed Care Contract Section 8.1.24.15, the Uniform Managed Care Manual Chapter 16.1, and the Texas Medicaid Provider Procedures Manual, Children’s Services Handbook, Chapter 2.14, Prescribed Pediatric Extended Care Centers.
 
Medicaid managed care organizations also must comply with Title 1 Texas Administrative Code, Part 15, Chapter 363, Subchapter B, Prescribed Pediatric Extended Care Centers.

4410 Assessment for Prescribed Pediatric Extended Care

Revision 22-2; Effective September 1, 2022

The Nursing Care Assessment Module (NCAM) of the STAR Kids Screening and Assessment Instrument (SK-SAI) contains assessment questions for services in a Prescribed Pediatric Extended Care Center (PPECC). The following information in the SK-SAI core module are triggers for the NCAM and may indicate the member requires ongoing nursing services:

• A current authorization for private duty nursing (PDN);
• A skilled nursing visit or PDN is provided in a school or day program;
• Member experienced one or more planned or unplanned inpatient acute hospital admissions or a nursing home stay in the past year;
• Member requires enteral or parenteral feeding;
• Member received any of the following treatments in the last 30 days:
  • Chemotherapy;
  • Dialysis;
  • Intravenous (IV) medication;
  • Oxygen therapy;
  • Radiation;
  • Suctioning;
  • Tracheotomy care;
  • Transfusion;
  • Ventilator;
  • Wound care;
  • Nebulizer;
  • Urinary catheter care –insertion or maintenance;
  • Comatose or persistent vegetative state – manage care'
  • Continuous positive airway pressure (CPAP) or Bilevel Positive Airway Pressure (BiPAP);
  • Chest percussive therapy;
  • Active medication adjustment;
  • Intermittent positive pressure breathing (IPPB); and/or
  • Seizure management; and
• The member is being assessed for Community First Choice (CFC) services or the Medically Dependent Children Program (MDCP).

If triggered, the service coordinator completes the NCAM to determine the member's nursing needs. Based on the assessment, the service coordinator develops a recommended service plan for the services of a PPECC. The service coordinator works with the member or their legally authorized representative to locate an appropriate provider and sends an authorization to the selected provider.

Members who have received an NCAM assessment and been approved for PDN services do not require a new assessment if they choose a PPECC unless there is a change in condition and additional nursing hours are needed. MCOs who have PPECC providers available in the service area are expected to provide information to members who qualify for ongoing nursing services about their options of PDN, PPECC or a combination of both.

A member has a choice of PDN, PPECC or both, as long as the services are not provided at the same time. Example: Member has PDN from 7 a.m. to 8 a.m., PPECC from 9 a.m. to 2 p.m. and PDN in the evening.

Note: If an individual qualifies for PDN, the individual will qualify for PPECC.

4411 Authorization Requirements

Revision 20-2; Effective September 1, 2020

Initial, reauthorization and revision requests for Prescribed Pediatric Extended Care Center (PPECC) services must include the following documentation:

• physician order for services (a physician signature on the PPECC plan of care (POC) serves as a physician order for authorization purposes);
• a POC developed by the PPECC;
• all required prior authorization forms listed in the Texas Medicaid Provider Procedures Manual or MCO forms if they contain comparable content; and
• signed consent of the participant or participant's responsible adult documenting the choice of PPECC services. The signed consent must include:
  • an acknowledgement by the participant or the participant's responsible adult that they have been informed that other services such as private duty nursing might be reduced as a result of accepting PPECC services; and
  • consent to share the participant's personal health information with the participant's other providers, as needed to ensure coordination of care.

Forms available online for PPECC include:

• Comprehensive Care Plan (CCP) Prior Authorization Request (requires ordering physician signature).
• PPECC POC (requires ordering physician, PPECC registered nurse (RN) and member/responsible adult signature). Note: Providers may use their own POC form, but it must contain the required elements per the Texas Medicaid Provider Procedures Manual.
• Nursing Addendum to Plan of Care for Private Duty Nursing and/or PPECC (requires ordering physician, PPECC RN and member/responsible adult signature). This form contains required individual and physician acknowledgements and consent.

When an MCO decides to use its own forms for PPECC authorizations, the forms must be equivalent to the fee-for-service forms and are subject to approval by HHSC.

Note: A separate authorization is not required for transportation to a PPECC. A member or LAR may decline PPECC transportation services.

4412 Reassessment and Reauthorization

Revision 20-2; Effective September 1, 2020

The need for, and the amount and duration of services from, a Prescribed Pediatric Extended Care Center (PPECC) must be reassessed by the PPECC provider:

• 90 days following initial authorization; and
• every 180 days thereafter; or
• when requested due to a change in the member's health; or
• when the authorized services are not commensurate with the Member’s medical needs.

A physician order must be renewed with any reassessment.

4420 Providers of Prescribed Pediatric Extended Care

Revision 22-2; Effective September 1, 2022

A Prescribed Pediatric Extended Care Center (PPECC) must be currently licensed (temporary, initial or renewal license), comply with 56 Texas Administrative Code. Chapter 550 (relating to Licensing Standards for Prescribed Pediatric Extended Care Centers), and be contracted with a member’s STAR Kids managed care organization (MCO) to provide services to that member. Contractual provisions for continuity of care apply. PPECCs do not provide emergency services. PPECCs must follow the safety provisions in state PPECC licensure requirements, including the adoption and enforcement of policies and procedures for a member’s medical emergency. PPECCs must call for emergency transport to the nearest hospital when emergency services are needed by a member in a PPECC. Per PPECC licensure requirements, services are non-residential, must be included in a PPECC plan of care (POC), and are limited to no more than 12 hours in a 24-hour period. Services must not be rendered overnight (9 p.m. to 5 a.m.).

A POC must include components as detailed in the Texas Medicaid Provider Procedure Manual and PPECC medical policy. These components include:

• Member's name, date of birth and Medicaid number;
• PPECC's name, Texas Provider Identifier (TPI), National Provider Identifier (NPI) and hours of operation, as well as address, telephone and fax numbers;
• Ordering physician's name, telephone number, TPI and NPI;
• Date the PPECC nursing assessment was completed and name, title and credentials of the registered nurse (RN) who completed the POC with their dated signature;
• Name, title and credentials of the team member who completed the POC with their dated signature;
• Date the member was last seen by the ordering physician;
• Requested start of care date for PPECC services;
• All pertinent diagnoses and known allergies;
• Nursing services to be provided, including amount, duration and frequency;
• Member's prognosis;
• Member's mental status;
• Rehabilitation potential;
• Equipment and/or supplies required;
• Therapies (occupational, physical, speech, and respiratory care), including how those therapies are accessed, amount, duration and frequency. Therapies provided in the PPECC, as well as outside the PPECC (e.g., school based), must be documented;
• Other prescribed services, including amount, duration and frequency;
• Nutritional requirements, including type, method of administration and frequency;
• Medications, including the dose, route, frequency and any medication-related allergies if known;
• Treatments, including amount and frequency;
• Wound care orders and measurements;
• Safety measures to protect against injury;
• Functional developmental services and psychosocial services, including amount, duration and frequency;
• Name, telephone number and signature of the responsible adult;
• Member’s emergency contact name and telephone number;
• Confirmation that a signed contingency plan is in place in circumstances when PPECC services are not available (e.g., fire, flood, windstorm or electrical malfunctions), and for emergencies that occur while the member is in the care of the PPECC;
• List of services the member receives in the home and school settings. [e.g., Early Childhood Intervention (ECI), therapies, School Related Health Services (SHARS), personal care services (PCS), private duty nursing (PDN), therapies, skilled home health, case management services, hospice, and Medicaid waiver programs such as Medically Dependent Children Program (MDCP), Home and Community-based Services (HCS), Deaf Blind with Multiple Disabilities (DBMD), Texas Home Living (TxHmL) and Community Living Assistance and Support Services (CLASS)].
  • Note: Services provided under these programs will not prevent a member from obtaining medically necessary services;
• Member-specific measurable goals, including, if receiving PDN, the goal of ensuring coordination of ongoing skilled nursing services with the PDN provider;
• Responsible adult training needs;
• Prior and current functional or medical limitations;
• Permitted activities;
• Member's scheduled days and hours of attendance;
• Confirmation of a discharge plan, including instructions for timely discharge or referral;
• Method of transportation;
• PDN provider name, TPI, NPI, telephone, address and fax number, if known;
• Ordering physician signature and date of signature;
• Transportation services needed by a member to access PPECC service (a non-emergency ambulance must not be used for transport to and from a PPECC); and
• Services outlined in the Texas Administrative Code, Title 1, Part 15, Chapter 363 (Texas Health Steps Comprehensive Care Program), Subchapter B (Prescribed Pediatric Extended Care Center Services), §363.209 (Benefits and Limitations).

The following services may be rendered at a PPECC place of service, but are not considered part of the PPECC services and must be billed separately by a provider contracted with the STAR Kids MCO:

• Speech, physical, and occupational therapies (including therapies rendered by a home health agency);
• Certified respiratory care services;
• Early intervention services provided through the ECI program, which are subject to ECI policies.

In accordance with 2.14.1 of the Texas Medicaid Provider Procedures Manual, Children’s Services Handbook, therapy services (occupational, speech, physical and respiratory) rendered in a PPECC must be provided by:

• therapists employed by or contracted with the PPECC; or
• therapists contracted with the MCO but not employed by, or contracted with, the PPECC.

Therapy providers must be Medicaid enrolled and separately contracted and credentialed with the MCO, even if they are employed by, or contracted with, the PPECC. Therapy services must be authorized and billed separately from PPECC services, and the MCO's claims systems must accommodate PPECCs as a place of service for therapy services.

4430 Private Duty Nursing and Prescribed Pediatric Extended Care Center Services

Revision 20-2; Effective September 1, 2020

See 4310, Private Duty Nursing and Prescribed Pediatric Extended Care Services, for details on coordination of services between PDN and PPECC. Both PDN and PPECC are ongoing skilled nursing services and are considered equivalent levels of nursing care. A member has a choice to receive PDN, PPECC or a combination of both services.

Revision 17-1; Effective June 1, 2017

Day Activity and Health Services (DAHS), also called adult day care, is a Medicaid state plan service available to STAR Kids members ages 18 and older who require the service because of a chronic medical condition and are able to benefit therapeutically from the service. DAHS provides attendant care in a facility setting under the supervision of a nurse. Services include nursing, physical rehabilitation, nutrition, social activities and transportation when another means of transportation is unavailable. STAR Kids managed care organizations may not require DAHS providers to obtain a denial or explanation of benefits from a member's primary insurance before seeking reimbursement for DAHS.

4510 Assessment for Day Activity and Health Services

Revision 22-2; Effective September 1, 2022

The potential for therapeutic benefit must be established by a physician's assessment and requires a physician's order.

A Day Activity and Health Services (DAHS) facility nurse must complete a health assessment for each STAR Kids member at the facility. The assessment may be conducted by a registered nurse (RN) or licensed vocational nurse (LVN), based upon the member's condition at the time of initial assessment. The DAHS facility nurse completes a health assessment at either the facility or the member's home. Health assessments must be conducted, at minimum, when:

• members need initial assessment for prior authorization by a STAR Kids managed care organization;
• members transfer to a new facility (conducted by the new facility);
• at reauthorization; and
• the DAHS nurse determines a member needs to be reassessed.

The member or their legally authorized representative must sign the health assessment each time the nurse completes or revises the form. The health assessment must identify specific conditions that may affect a member's functioning.

4511 Reassessment for Day Activity and Health Services

Revision 22-2; Effective September 1, 2022

Reassessment by a physician is required at least every 12 months for continued authorization. For this service, a physician assessment must be no older than 90 days from the date at which an authorization is requested.

A member is reassessed at regular intervals by the facility nurse. In addition, the facility nurse assesses the member for nursing, physical rehabilitation, and nutritional services when:

• a member first enters the facility;
• transferring from another Day Activity and Health Services facility; and
• a member's condition changes. If the change in condition necessitates, the facility nurse coordinates with the member's service coordinator or physician for a physician assessment.

4520 Day Activity and Health Services Providers

Revision 22-3; Effective Dec. 1, 2022

To provide Day Activity and Health Services (DAHS), a facility must hold a current license from the Texas Health and Human Services Commission and comply with Texas Administrative Code, Title 40, Part 1, Chapter 98, Adult Day Activity and Health Services Requirements.

DAHS facilities are responsible for:

• Nursing services, which include a member’s nursing assessment, assistance with prescribed medications, counseling concerning health needs, and supervision of personal care services (PCS).
• Physical rehabilitative services, which include restorative nursing and group and individual exercises with range of motion exercises.
• Nutrition services, which include:
  • one hot noon meal a day;
  • a mid-morning and mid-afternoon snack;
  • preparation of foods required for special diets; and
  • dietary counseling and nutrition education for the individual and their family.
• Transportation, including to and from the facility, on an activity outing, and to provide therapies if the member requires specialized services on days of attendance at the DAHS facility. The provider must:
  • coordinate the use of other transportation resources within the community;
  • make every effort to have families transport individuals;
  • manage upkeep and operation of facility vehicles, including liability insurance. Vehicles used by the facility must be maintained in a condition to meet the vehicle inspection requirements of the Texas Department of Public Safety; and
  • have sufficient staff to ensure the safety of members being transported to and from their homes.

• Activities and other supportive services:
  • Activities offered at the facility must be meaningful, fun, therapeutic and educational.
  • A provider must offer at least three different scheduled activities in at least one or more of the following activities:
    • exercise;
    • games;
    • educational or reality orientation; and
    • crafts.
  • A provider must offer at least one of the following activities, at cost to the provider, monthly:
    • trips or special events; or
    • cultural enrichment.

Revision 22-3; Effective Dec. 1, 2022

The Medically Dependent Children Program (MDCP) provides respite, flexible family support services, minor home modifications, adaptive aids, transition assistance services, supported employment, and employment assistance. This is to prevent placement of individuals in long-term care facilities who are medically dependent and under 21 years old and support deinstitutionalization of nursing facility residents under 21 years old.

Only members who are assessed as meeting medical necessity (MN) and who have a slot in the MDCP waiver are eligible for MDCP services. Federal guidelines require that members must need and use one or more waiver services to qualify and maintain eligibility for MDCP. The minimum utilization of MDCP service required to maintain MDCP eligibility is dependent upon the member’s Medicaid eligibility and whether they utilize Community First Choice (CFC), as described in Section 1530, Unmet Need for at Least One Waiver Service.

The managed care organization (MCO) service coordinator must inform all members receiving MDCP services of the requirements outlined in Section 1530 and the following:

• If the member’s eligibility is Medical Assistance Only (MAO) and:
  • CFC has been authorized, at a minimum, one MDCP service must be used at least once a month to qualify and maintain enrollment in MDCP.
  • CFC has not been authorized, at a minimum, one MDCP service must be used at least once during the member’s ISP year to qualify and maintain enrollment in MDCP.
• If the member’s eligibility is not MAO and CFC has been authorized, at a minimum, at least one MDCP service must be used during the member’s ISP year. The member must receive monthly monitoring by the MCO if services are furnished on a less than monthly basis to qualify and maintain enrollment in MDCP.

If the member is not meeting the minimum required service utilization, the MCO must notify the Program Support Unit (PSU) following requirements in Section 6270, Denial/Termination Due to Failure to Meet Other Program Requirements. If a member is offered enrollment in MDCP or at an MDCP member's reassessment, during the STAR Kids assessment, using the STAR Kids Screening and Assessment Instrument (SK-SAI), the service coordinator must discuss the member's needs relating to the available MDCP services. The service coordinator must develop a recommended individual service plan (ISP) if the member's Resource Utilization Group (RUG) is not known, as the RUG determines the member's budget.

Example: The service coordinator could ask;

• the member or their caregiver if they would like respite or have a desire for employment services. 
• if the member requires adaptive aids, minor home modifications, or could benefit from flexible family support services
• which services the member or caregiver would like more of, should the member's budget be unknown during the assessment.

Based on the discussion, the service coordinator could develop a recommended ISP for that member and work with the member or caregiver in person or by phone to develop a final service plan once the member's budget is known.

Revision 22-3; Effective Dec. 1, 2022

4710 Medically Dependent Children Program Respite Services

Revision 22-3; Effective Dec. 1, 2022

Respite is a service that provides temporary relief from caregiving to the member’s primary caregiver during the times when the primary caregiver would normally provide care. The primary caregiver may be the member’s parent(s), guardian, a family member or spouse, if married. STAR Kids managed care organizations (MCOs) may not require respite providers to obtain a denial or explanation of benefits from a member's primary insurance before seeking reimbursement for respite services.

In-home respite may be delivered by an attendant, LVN, or RN through a home and community support services agency (HCSSA), also called a home health agency, or through the Consumer Directed Services (CDS) option. In-home respite is not limited to the individual’s place of residence. Respite may also be provided in other community settings when the situation does not exceed the limitations documented in Section 4720, Respite Limits. Other community settings could include the park, the respite provider’s home, or a home of the member's relative. Out-of-home respite may be provided in a facility setting, such as a nursing facility or hospital, or in a camp setting.

Respite is intended to provide relief to the primary caregiver. It may only be provided when a member's primary caregiver would normally provide the member's care. Respite may not be delivered while the member is in school or in a school setting. Respite must not be provided at the same time as a duplicative service, such as Community First Choice (CFC) or private duty nursing (PDN). Duplication occurs when Medically Dependent Children Program (MDCP) respite provided by a nurse is rendered at the same time as another in-home nursing service (such as PDN), or when MDCP respite provided by an attendant is rendered at the same time as another attendant care service (such as CFC). Because respite provides relief to the primary caregiver if the caregiver would normally be providing services, respite may be authorized at the same time. For example, a nurse providing PDN is in the member's home for the purpose of such services as suctioning or monitoring vitals and an MDCP respite attendant is in the home at the same time providing CFC to the member to relieve the caregiver of tasks they would normally be responsible for performing. Circumstances which require two personnel for a two-person transfer are not considered a duplication of services. In that case, the private duty nurse and MDCP respite attendant could collaborate to accomplish the transfer. Note: Respite must not be authorized in place of PDN where PDN is most appropriate. Respite is intended to provide relief to the primary caregiver and must only be authorized for that purpose.

STAR Kids MCOs must determine the number of units of respite to authorize for an MDCP member, based on the member or legally authorized representative's preferences, level of care, and the member's approved cost limit. Specialized nursing rates will be paid when a member requires, as determined by a physician, daily skilled nursing to cleanse, dress, and suction a tracheostomy or daily skilled nursing assistance with ventilator or respirator care. The member must be unable to do self-care and require the help of a nurse for the ventilator, respirator or tracheostomy care. MCOs must develop internal processes for respite service schedules, schedule changes, and policies regarding setting aside funds within the individual service plan (ISP). MCOs must develop a process to allow for flexible schedules and allow an MDCP member to "bank" respite hours to use at later point in the ISP year. MCOs must allow members to have flexibility in the use of respite hours, allowing members to carry over respite hours from week to week and month to month. A member cannot carry respite hours over from an expiring ISP to the new ISP. 

4711 In-Home Respite

Revision 22-2; Effective September 1, 2022

In-home respite is not limited to the individual’s place of residence. Respite may also be provided in other community settings, which could include the park, the respite provider’s home or a home of the individual’s relative. In-home respite may be provided by a licensed Home and Community Support Services Agency (HCSSA), also called a home health agency, or the provider employed by a member or their legally authorized representative under the Consumer Directed Services (CDS) option.

A member's in-home respite is limited by the amount of the member's cost limit. If the member chooses the CDS option, the member is limited by their available budget. Managed care organizations (MCOs) may have additional policies and procedures regarding reserving capacity in a member's budget. The provision of in-home respite is documented on the individual service plan (ISP).

4712 Attendant with Delegated Tasks

Revision 22-2; Effective September 1, 2022

A delegated task is defined as a task that a physician or registered nurse (RN) delegates in accordance with state law. In general, the Texas Board of Nursing (BON) defines nurse delegation as authorizing an unlicensed person to provide nursing services while retaining accountability for how the unlicensed person performs the task. In brief, the Texas Occupations Code indicates a physician may delegate to a qualified and properly trained person acting under the physician's supervision any medical act that a reasonable and prudent physician would find within the scope of sound medical judgment to delegate. Only an RN may delegate to an attendant under their supervision, per BON rules. A member with a skilled task need may use an attendant with delegated tasks if a physician or RN delegates the skilled task required to meet the member's needs.

If the member does not have a skilled nursing task need for the delivery of respite, they do not have a need for an attendant with delegated tasks. If the member or primary caregiver requests the use of an attendant with delegated tasks, but the nurse service coordinator or the Home and Community Support Services Agency (HCSSA) nurse determines the use of this provider type places the individual's health and welfare at risk, the service coordinator should not authorize an attendant with delegated tasks to deliver respite, unless determined appropriate by the member's physician.

If a member or legally authorized representative (LAR) employs an attendant under the Consumer Directed Services (CDS) option, delegation of certain tasks is not required. Form 1733, Employer and Employee Acknowledgement of Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed Services, outlines what services cannot be delegated, such as specific tasks involved in the implementation of the care plan that require professional nursing judgment or intervention. If the member or their LAR is directing the member's services, they must sign Form 1585, acknowledging responsibility for the training and oversight of an attendant.

4713 Out-of-Home Respite

Revision 22-2; Effective September 1, 2022

Respite may be provided out of the home if indicated in a physician's order or if the member and/or their legally authorized representative prefer. Out-of-home respite providers are:

• special care facilities licensed by the Texas Health and Human Services Commission (HHSC);
• day care facilities licensed by the Texas Department of Family and Protective Services (DFPS);
• hospitals licensed by DSHS and accredited by the Joint Commission on Accreditation of Healthcare Organizations;
• nursing facilities licensed by the Texas Health and Human Services Commission (HHSC);
• camps licensed by DSHS and accredited by the American Camping Association; and
• foster families approved by a DFPS child placing agency.

Facility-based respite is limited to 29 days per the individual service plan period. The 29-day limit applies to the total number of days a member receives respite in a hospital or nursing facility.

4720 Respite Limits

Revision 22-2; Effective September 1, 2022

Respite may only be provided during the time the primary caregiver would usually provide care to the member. Respite may not be provided during the time the primary caregiver is at work, attending school or in job training. All respite settings must be located within the state of Texas.

Title 42 of the Code of Federal Regulations §441.301(b)(1)(ii) requires that home and community based services, like Medically Dependent Children Program (MDCP) services, not be provided in an institution. However, respite may be provided in a hospital or nursing facility (NF) only if the sole reason for the member's admission is respite. For example, if a member is admitted to a hospital for reasons such as illness, surgery or stabilization/treatments, respite must not be authorized concurrently.

The member may request to exceed the 29-day facility-based respite limit. Within five days of the request to exceed the 29-day limit, the managed care organization (MCO) must review the individual’s needs and the primary caregiver’s ability to meet those needs, and determine if the request falls within the respite criteria. The MCO must ensure there is no danger to the member’s health and welfare.

Respite may not be provided in a setting in which identical services are already being provided. This means that a nurse may not provide respite to a member who is receiving out-of-home respite in a camp. Likewise, an attendant may not provide respite to a member receiving out-of-home respite in an NF. Respite may not be delivered by the:

• primary caregiver;
• member's spouse; or
• member's parent, representative, guardian or managing conservator, if the individual is under age 18.

4730 Reserved for Future Use

Revision 17-1; Effective June 1, 2017

 

4740 Reserved for Future Use

Revision 17-1; Effective June 1, 2017

 

4750 Flexible Family Support Services

Revision 19-1; Effective June 3, 2019

Flexible family support services (FFSS) are individualized and disability-related services that support a member to participate in age-appropriate activities such as:

• child care;
• independent living; and
• post-secondary education.

FFSS include personal care supports for basic activities of daily living and instrumental activities of daily living, skilled task and delegated skilled task supports. FFSS promote community inclusion in typical child and youth activities through the enhancement of natural supports and systems and through recognition that these supports may vary by child, provider, setting and daily routine. Flexible family support services may be delivered by the Home and Community Support Services Agency (HCSSA) and also may be delivered by attendants or nurses employed through the Consumer Directed Services option. FFSS are documented on the individual service plan. STAR Kids managed care organizations may not require FFSS providers to obtain a denial or explanation of benefits from a member's primary insurance before seeking reimbursement for FFSS.

4751 Flexible Family Support Services in Child Care

Revision 22-2; Effective September 1, 2022

The member's parent or guardian is responsible for basic child care either in or out of the member's home. Flexible family support services (FFSS) support the member's participation in child care when the service provided by the child care does not support the member's disability-related needs. If the member's child care is not able to meet the member's activities of daily living, instrumental activities of daily living, skilled task, non-skilled task or delegated skilled task needs, the service coordinator may authorize FFSS.

To determine the need for FFSS for participation in child care, the service coordinator must discuss the parent's or guardian's plan for obtaining basic child care and whether it will be provided in or out of the member's home or both. The delivery of FFSS does not include basic child care, which is watchful attention or supervision of the member while the primary caregiver is at work, in job training, or at school and not available. These remain responsibilities within the service delivered by the child care provider.

The caregiver's cost for child care does not impact the member's need for FFSS. The service coordinator must determine the number of hours needed to support the member's needs within the Medically Dependent Children Program (MDCP) cost limit. The service coordinator should ask the caregiver about the member's personal and skilled task needs and the time needed to address those needs. The service coordinator should discuss the skill level required to assist the member to address necessary safeguards that ensure the member's health and welfare.

FFSS does not replace personal care services (PCS) provided through Texas Health Steps (THS) or Community First Choice (CFC). FFSS are provided when a member regularly participates in child care in the home or out of the home or participates in a community program or educational service. FFSS are authorized because of a change in the child's condition or when because of the child's condition, the child’s needs cannot be met. In these instances, additional care is required.

4752 Flexible Family Support Services for Independent Living

Revision 22-2; Effective September 1, 2022

A member may indicate a desire for increased independence as they mature. If the member needs assistance with activities of daily living (ADLs), instrumental activities of daily living (IADLs), skilled task, non-skilled task or delegated skilled task, the service coordinator may authorize flexible family support services (FFSS) to help the member with their goals for independent living.
Independent living can be an arrangement that maximizes independence and self-determination and offers opportunities to be as self-sufficient as possible. Although independent living is not a Medically Dependent Children Program (MDCP) service, an independent living arrangement can provide life-skills training to assist members in acquiring the skills they will need to live independently as adults.

To determine the need for FFSS for independent living, the service coordinator must discuss the member's and primary caregiver's plan for the member's independent living. When identifying the member's need for this service, the service coordinator should address age appropriateness for the tasks required to meet these needs. The service coordinator must determine the amount of FFSS needed to support the member's needs. The service coordinator should discuss the skill level required to assist the member and the appropriateness of the living arrangement and service delivery regarding the member's age, health and welfare. FFSS may be used only when the primary caregiver is working, attending school or participating in job training.

4753 Flexible Family Support Services in Post-Secondary Education

Revision 22-2; Effective September 1, 2022

A member can access flexible family support services (FFSS) to participate in post-secondary education. Post-secondary education institutions do not assist students with activities of daily living (ADL), instrumental activities of daily living (IADL), skilled task, non-skilled task or delegated skilled task needs. If a member has an ADL, IADL, skilled task, non-skilled task or delegated skilled task need prohibiting the member from participating in post-secondary education, the service coordinator may authorize FFSS, so the member may participate in post-secondary education.

A member may enroll in a post-secondary school after first attending a secondary school, such as a high school. A post-secondary education may include vocational education and training, as well as participation in a college or university. These educational institutions are not subject to the Individuals with Disabilities Education Act. Post-secondary institutions can provide academic adjustments, but do not support the member's personal, skilled and delegated skilled task needs.

To determine the need for FFSS in post-secondary education, the service coordinator must identify the member's need for assistance and the amount of FFSS needed to support the member's needs. The service coordinator should identify the member's personal and skilled task needs and the amount of time needed to address those needs. The service coordinator should discuss the skill level required to assist the member and address necessary safeguards to ensure the member's health and welfare.

4754 Flexible Family Support Services Requiring Delegated Tasks

Revision 22-2; Effective September 1, 2022

A delegated task is defined as a task that a physician or registered nurse (RN) delegates in accordance with state law. In general, the Texas Board of Nursing (BON) defines nurse delegation as authorizing an unlicensed person to provide nursing services while retaining accountability for how the unlicensed person performs the task. In brief, the Texas Occupations Code indicates a physician may delegate to a qualified and properly trained person acting under the physician's supervision any medical act that a reasonable and prudent physician would find within the scope of sound medical judgment to delegate. Only a Home and Community Support Services Agency (HCSSA) nurse may delegate to an attendant under their supervision, per BON rules. A member with a skilled task need may use an attendant with delegated tasks if a practitioner or RN delegates the skilled task required to meet the member's needs.

If the member does not have a skilled task need for the delivery of flexible family support services (FFSS), they do not have a need for an attendant with delegated tasks. If the member or primary caregiver requests the use of an attendant with delegated tasks, but the service coordinator or the HCSSA provider determines the use of this provider type places the individual's health and welfare at risk, the service coordinator should not authorize an attendant with delegated tasks to deliver respite, unless determined appropriate by the member's physician.

If a member or their legally authorized representative (LAR) employs an attendant under the Consumer Directed Services (CDS) option, delegation of certain tasks is not required under the CDS option. Form 1585, Acknowledgment of Responsibility for Exemption from Nursing Licensure for Certain Services Delivered through CDS, outlines what services cannot be delegated, such as specific tasks involved in the implementation of the care plan that require professional nursing judgment or intervention. If the member or their LAR is directing the member's services, he must sign Form 1585, acknowledging responsibility for the training and oversight of an attendant.

4760 Flexible Family Support Services Limits

Revision 22-2; Effective September 1, 2022

Flexible family support services (FFSS) may be used only when the primary caregiver is working, attending school or participating in job training, and are delivered in a setting where the delivery of similar supports is not already required or included as part of the service. For this reason, the service coordinator may not authorize FFSS during the same time period the individual receives personal care services (PCS) or Community First Choice (CFC).

42 Code of Federal Regulations §441.301(b)(1)(ii) requires that Medically Dependent Children Program (MDCP) services, including FFSS, may not be provided to a member who is admitted to a hospital, or is a resident of a nursing facility (NF) or intermediate care facility for individuals with an intellectual disability or related conditions (ICF-IID).
The service coordinator may not authorize FFSS during the member's school hours in primary or secondary educational settings.

Revision 22-2; Effective September 1, 2022

4810 Adaptive Aids

Revision 19-1; Effective June 3, 2019

Adaptive aids are devices necessary to treat, rehabilitate, prevent or compensate for conditions resulting in disability or loss of function and enable members to:

• perform activities of daily living (ADLs); or
• control the environment in which they live.

A member must exhaust any applicable Medicare, Medicaid or other third-party resources for durable medical equipment and adaptive aids before adaptive aids available under the Medically Dependent Children Program (MDCP) are authorized. A member may take an adaptive aid to an out-of-home respite facility for use while residing there.

4811 Service Limits on Adaptive Aids

Revision 22-3; Effective Dec. 1, 2022 

The service limit on all adaptive aids combined is $4,000 per annual individual service plan (ISP) period. The amount paid for an adaptive aid must be documented on Form 2416, Minor Home Modifications and Adaptive Aids Service Authorization, and retained in the member's case file. 

Adaptive aids are available through the Medically Dependent Children Program (MDCP) only after benefits available through Medicare; Medicaid, including the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program, known in Texas as Texas Health Steps – Comprehensive Care Program (THSteps-CCP); or other third party resources have been exhausted. Items reimbursed with waiver funds are only accessible for items not covered under the state plan.

Health and safety of the individual are ensured through the use of non-waiver services, the Medicaid State Plan, and THSteps-CCP. 

The services under the waiver are limited to additional services not otherwise covered under the state plan, but consistent with waiver objectives of avoiding institutionalization.

After any applicable benefits (e.g., durable medical equipment) are exhausted, adaptive aids, including repair and maintenance not covered by warranty (i.e., batteries), covered through MDCP include, but are not limited to, the following:

• van lifts;
• vehicle modifications;
• jump seats;
• tumble form chairs;
• feeder seats;
• medically appropriate strollers;
• barrier-free lifts;
• stair lifts;
• environmental control units;
• alarm systems;
• support rails;
• electrical work related to use of authorized adaptive aids;
• installation of authorized adaptive aids; and
• repairs to adaptive aids.

This is not an exhaustive list. For adaptive aids not specifically listed above, the service planning team must determine the member has an established assessed need and a compromised health status without the requested equipment or supplies. Items must be prescribed by a physician and be determined to meet the criteria specified in 4810, Adaptive Aids.

The managed care organization (MCO) may authorize bids for adaptive aids, such as vehicle modifications, as applicable. The cost of these bids does not count against the member's annual limit for adaptive aids.

If the cost of a requested adaptive aid exceeds the service limit, the MCO may approve the request only if the member agrees to pay any costs that are in excess of the service limit. The MCO must document the member's agreement to pay these costs in the member's case file. MCOs may also choose to pay the excess costs on a case-by-case basis with MCO funds. Documentation must include, at a minimum, a description of the adaptive aid, rationale for exceeding the service limit, the cost incurred to the MCO, the cost incurred to the member, the member's signature, the date of the member's agreement, and signature of the provider. Documentation must be on file prior to the MCO authorizing an adaptive aid that exceeds the service limit.

4812 Time Frames for Adaptive Aids

Revision 22-2; Effective September 1, 2022

When an adaptive aid (AA) is included in an individual service plan (ISP), the managed care organization (MCO) must purchase and ensure delivery of the AA within 14 business days of being authorized (except for vehicle modifications), counting from one of the following dates, whichever is later:

• the start date of the ISP; or
• the date of the ISP revision, if the AA service is added after the ISP start date.  

The MCO must document and notify the member of any delay in delivering the AA, the reason for the delay and the new proposed delivery date. The notification must be provided on or before the 14th business day following authorization. If the provider does not deliver the AA by the new proposed date, the MCO must document and notify the member about any additional delays until the AA is delivered. Throughout the process, the MCO must continue to meet the member’s health and safety needs. The MCO must work with the provider and member to ensure timely delivery of the AA. 

4820 Minor Home Modifications

Revision 22-2; Effective September 1, 2022

A minor home modification is a physical modification to a member's residence necessary to prevent institutionalization or support de-institutionalization. Minor home modifications are necessary to ensure the health, welfare and safety of the member or to enable the member to function with greater independence in their home. If a home modification is requested and the member or their legally authorized representative (LAR) does not own the home in which the modification will take place, the member, LAR, or the service coordinator must obtain written agreement from the homeowner before a modification is authorized. STAR Kids managed care organizations (MCOs) may not require minor home modification providers to obtain a denial or explanation of benefits from a member's primary insurance before seeking reimbursement for minor home modifications services.

4821 Service Limits on Minor Home Modifications

Revision 22-2; Effective September 1, 2022

The minor home modification lifetime limit is $7,500. The service coordinator may authorize up to $300 per the individual service plan (ISP) period for maintenance or repairs of minor home modifications previously approved and reimbursed with waiver funds. The service coordinator does not include $300 maintenance and repair limit as part of the $7,500 lifetime limit. The amount paid for a modification or for the repair of a minor home modification must be documented on Form 2416, Minor Home Modifications and Adaptive Aids Service Authorization, and retained in the member's case file. A minor home modification must not create a new structure or add square footage to the home.

The managed care organization (MCO) may authorize bids for minor home modifications, as applicable. The cost of these bids does not count against the member's lifetime limit for minor home modifications.

Minor home modifications are limited to:

• purchase and installation of permanent and portable ramps not covered by other sources;
• widening of doorways;
• modification of bathroom facilities; and
• modifications related to the approved installation or modification of ramps, doorways or bathroom facilities.

Minor home modifications must:

• adhere to Americans with Disabilities Act (ADA) requirements;
• meet Texas Accessibility Standards;
• meet all applicable state and/or local building codes; and
• have a minimum one-year warranty.

Minor home modifications do not include the use of deluxe materials, such as granite, marble or high-end fixtures.

If a request for repair or maintenance to a minor home modification is not covered by the provider's warranty, the service coordinator may authorize up to $300 for the member or their legally authorized representative to select a provider contracted with the STAR Kids MCO. The $300 limit is available per the member’s ISP year for maintenance and repair and is not included in the $7,500 lifetime minor home modification service limit.

If the cost of a requested minor home modification exceeds the service limit, the MCO may approve the request only if the member agrees to pay any costs that are in excess of the service limit. The MCO must document the member's agreement to pay these costs in the member's case file. Documentation must include, at a minimum, a description of the home modification, rationale for exceeding the service limit, the cost incurred to the MCO, the cost incurred to the member, the member's signature, the date of the member's agreement, and signature of the provider. Documentation must be on file prior to the MCO authorizing a home modification that exceeds the service limit.

4822 Time Frames for Minor Home Modifications

Revision 21-1; Effective April 1, 2021

When a minor home modification (MHM) is included in an individual service plan (ISP), the managed care organization (MCO) must ensure completion of the MHM within 90 business days after:

• the start date of the ISP; or
• the date of the ISP revision, if the MHM service is added after the ISP start date.  

The MCO must document and notify the member of any delay in completing the MHM, the reason for the delay and the new proposed completion date. If the provider does not complete the MHM by the new proposed completion date, the MCO must document and notify the member about the additional delay. Throughout the process, the MCO must continue to meet the member’s health and safety needs. The MCO must work with the provider and member to ensure timely completion of the MHM.

4830 Transition Assistance Services

Revision 22-3; Effective Dec. 1, 2022

The service coordinator must advise individuals who reside in a nursing facility (NF), or members whose Medically Dependent Children Program (MDCP) services are suspended due to NF placement, of the availability of Transition Assistance Services (TAS). TAS may be used if the individual needs assistance in setting up a household when relocating into the community from the NF. STAR Kids managed care organizations (MCOs) may not require TAS providers to obtain a denial or explanation of benefits from a member's primary insurance before seeking reimbursement for TAS. The individual may access TAS if they:

• plan to rent an apartment;
• plan to rent a house;
• have a home, but the utilities have been off while in the NF;
• have a home, but it may need cleaning, pest eradication or allergen control before it can be occupied again; or
• need belongings moved from the NF to the new residence.

TAS may be available to pay for non-recurring set-up expenses for individuals transitioning from NFs into MDCP and to individuals suspended from MDCP services due to a temporary NF placement. TAS may be used for those necessary expenses identified as barriers to the individual’s transition into the community to set up a household. TAS may include, but is not limited to, payment or purchases of:

• security deposits required to lease an apartment or house, or deposits required to establish utility services for the home;
• essential furnishings for the apartment or house;
• moving expenses required to move into the house or apartment; and
• site preparation services, such as pest eradication, allergen control or a one-time cleaning before occupancy.

The individual selects a TAS agency from the list of contracted agencies. The STAR Kids MCO may require the individual or their legally authorized representative (LAR) to attest that the items requested for TAS are the basic, essential needs required to move into the community, and they agree the TAS agency selected is authorized to make the purchases for them. The service coordinator must explain to the individual or their LAR that the service will not be authorized until the individual is determined eligible for MDCP waiver services, and notified in writing that they are eligible. The service coordinator must contact the individual or their LAR before certification to verify they have made arrangements for relocating to the community and has finalized a projected discharge date. The amount of TAS a member received must be documented on Form 8604, Transition Assistance Services (TAS) Assessment and Authorization.

4831 Deposits

Revision 22-2; Effective September 1, 2022

The service coordinator may authorize Transition Assistance Services (TAS) to pay deposits, which include security deposits for residential leases and household utilities, including basic telephone service. Security deposits or utility deposits must be in the individual’s name.

Residential Leases – A security deposit is a one-time expense and the amount may be no more than the equivalent of two months' rent. The service coordinator must not authorize TAS to pay rent. TAS may be accessed to pay for pet deposits only if the pet is the individual’s service animal.

Household Utilities – TAS may be used to pay for utility deposits to establish accounts in the individual’s name or to pay for arrears on previous utilities if the account is in the individual’s name and they will not be able to get the utilities unless the previous balance is paid. TAS cannot be used for payment toward utilities. TAS may be used to pay for a telephone since it is a basic need but may not be used to purchase minutes or services for the telephone. The managed care organization (MCO) may have internal policies regarding the type of telephone that may be authorized.

TAS funds can be used to pay for initial setup or reconnection fees for propane or butane service, including the minimal supply of fuel if the utility company requires a minimal supply of fuel to be delivered during the initial or reconnection service call.

Essential Furnishings – TAS household items that, if absent, would pose a barrier to the individual’s transition into the community. Essential furnishings purchased with TAS funds may include furniture, appliances, housewares and cleaning supplies.

Furniture – TAS can be used to purchase furniture such as a bed, recliner or dinette if the individual’s place of residence does not have the needed furniture and the absence of the item prevents the transition into the community.

Appliances – TAS can be used to purchase appliances such as a refrigerator, stove, washer, dryer, microwave oven, electric can opener, coffee pot or toaster if the individual identifies these appliances as needed items.

Housewares – TAS can be used to purchase basic housewares such as pots, pans, dishes, silverware, cooking utensils, linens, towels, a clock and other small items required to set up the household.

Cleaning Supplies – TAS can be used to purchase basic cleaning supplies such as a mop, broom, vacuum, brushes, soaps and cleaning agents required for the household.

Other – TAS can be used to purchase any special request from the individual not included in the general list that meets the criteria as a basic essential furnishing to transition into the community, if approved by the STAR Kids MCO.
 

4832 Moving Expenses

Revision 22-2; Effective September 1, 2022

Transition Assistance Services (TAS) can be used to pay for moving expenses, which may include the cost of moving the individual’s belongings from the nursing facility to the community residence, or delivery charges on approved TAS items.

Moving expenses may include the cost of a designated mover or retail store to deliver or move furniture, major appliances and other items approved as required for relocation to the community. Moving expenses do not include the cost of transporting the individual from the nursing facility to their residence in the community.

4833 Site Preparation

Revision 22-2; Effective September 1, 2022

Transition Assistance Services (TAS) can be used to pay for preparing the individual’s place of residence for occupancy if the current condition of the residence prevents the individual’s transition from the nursing facility. Site preparation purchased with TAS funds may include one-time expenses such as pest eradication, allergen control and residential cleaning.

Pest Eradication – TAS can be used if the residence has been unattended and needs some type of extermination.

Allergen Control – TAS can be used if the residence has been unattended or the individual is moving into a place that poses a respiratory health problem.

One-time Cleaning – TAS can be used if the individual’s residence has been unattended or the individual is moving into a private home or apartment where pre-move-in cleaning should not be expected. For example, a family friend has an empty house available but cannot provide the cleaning.

4834 Limits on Transition Assistance Services

Revision 22-2; Effective September 1, 2022

The service limit on Transition Assistance Services (TAS) has a $2,500 lifetime limit per individual. The amount paid for TAS must be documented on Form 2416, Minor Home Modifications and Adaptive Aids Service Authorization, and retained in the member's case file. The service coordinator must be as specific as possible when describing the items purchased. A nursing facility resident eligible for Medically Dependent Children Program (MDCP) services or members whose MDCP services are suspended due to nursing facility placement may receive a one-time TAS authorization if the service coordinator determines that no other resources are available to pay for the basic services or items needed by the individual. TAS may not be used for:

• monthly rent or mortgage expenses;
• current or future use of utilities;
• service upgrades;
• food items; or
• any diversional or recreational items or services, including televisions, video players or recorders, movies, games, computers, cable TV, satellite TV, exercise equipment, vehicles or other modes of transportation.

TAS does not include any items or services that may be accessed through other MDCP services, such as adaptive aids or minor home modifications. TAS is only available to individuals who are discharged from a nursing facility and require TAS to set up a household.

4835 Transition Assistance Services Agency Responsibilities

Revision 22-2; Effective September 1, 2022

The Transition Assistance Services (TAS) agency accepts all members referred by the managed care organization (MCO). Upon receipt of the authorization, the TAS agency must review the authorization carefully and contact the MCO if there are any questions regarding the authorization. This contact must occur by the next business day of receipt of the forms, and before any TAS purchase is made. The MCO contacts the member or their legally authorized representative (LAR), if necessary, to discuss the item in question. The MCO provides a revised TAS authorization within two business days if it clarifies an item is authorized or approves a change to the authorization.

The TAS agency purchases the authorized items/services and arranges and pays for the delivery of the purchased items, if applicable. The TAS agency only purchases services or items within the authorization made by the MCO. The TAS agency contacts the member or their LAR, if necessary, to coordinate service delivery. The TAS agency delivers the authorized services by the completion date recorded on the TAS authorization form. The agency provides a copy of the purchase receipts and any original product warranty information to the member. The TAS agency maintains the original purchase receipts, including sales tax, delivery or installation charges.

The TAS agency orally notifies the MCO of a delivery delay before the completion due date and documents the delay. The agency also contacts the member or the member's representative by the completion date to confirm that all authorized TAS services were delivered.

4836 Three-Day Monitor Requirement

Revision 17-1; Effective June 1, 2017

The managed care organization (MCO) monitors the member within three business days following the discharge date to assure the delivery of all services and items authorized through the Transition Assistance Services (TAS) agency. If the member reports that any items have not been delivered or services not performed, the MCO contacts the TAS agency by telephone and follows up in writing. Written documentation must be maintained in the member’s case record.

4837 Failure to Leave the Facility

Revision 22-2; Effective September 1, 2022

While the managed care organization (MCO) makes every effort to confirm the member has definite plans to leave the facility, there may be situations in which the member changes their mind or has a change in health making it impossible for them to relocate to the community as planned. In this situation, the MCO notifies the Transition Assistance Services (TAS) agency that the member is no longer moving and no further items are to be purchased.

The TAS agency must attempt to return any item(s) purchased on behalf of the individual and collect a refund for the purchase. The TAS agency also must attempt to recoup security, utility and other deposits paid on behalf of the individual. Failure to leave a facility does not count against a member's lifetime TAS limit.

• If the TAS agency is unsuccessful in returning the item(s) for monies paid, or the deposits paid on behalf of the individual cannot be recouped, the TAS agency is entitled to the cost of the item(s) and/or reimbursement for deposits paid, not to exceed the authorized amount. The TAS agency sends the MCO written notice stating the item(s) could not be returned or the deposits could not be recouped. The MCO contacts a local charity to donate the items and makes arrangements for pick up. The charity must serve individuals whose needs are similar to those of the individual for whom the items were purchased or must be dedicated to assisting the individual to establish a home.
• If the TAS agency is able to return the item(s) or receives the deposits back, the TAS agency is not entitled to reimbursement. If the TAS agency recoups part of the monies paid, the TAS agency is entitled to the costs of the item(s) or deposits less any monies recouped. Any claims that had been filed and paid for the item(s) or deposits would need to be adjusted by the TAS agency to pay the monies back to the MCO.
• If a service has already been provided (for example, pest eradication), the TAS agency is entitled to the cost of the service, not to exceed the authorized amount.

If the member is only in the community for a few days and returns to the nursing facility, the member keeps the item(s) purchased through TAS.

Revision 22-3; Effective Dec. 1, 2022

Texas Human Resources Code, Section 32.075 requires that all Medicaid waivers offer employment assistance (EA) and supported employment (SE). Employment services are intended to assist members to find employment and maintain employment. Employment services available for members in the Medically Dependent Children Program are EA and SE. STAR Kids managed care organizations may not require SE or EA providers to obtain a denial or explanation of benefits from a member's primary insurance before seeking reimbursement for SE or EA services.

4910 Employment Assistance

Revision 22-3; Effective Dec. 1, 2022

Employment assistance (EA) is provided to a member receiving Medically Dependent Children Program (MDCP) services to help the individual locate paid employment in the community and includes:

• identifying a member's employment preferences, job skills, and requirements for a work setting and work conditions;
• locating prospective employers offering employment compatible with a member's identified preferences, skills and requirements; and
• contacting a prospective employer on behalf of a member and negotiating the member's employment.

For any MDCP member, the service coordinator must ensure and document that employment services are not available to the member from the member's school district or other available community resource before authorizing EA services.

The service coordinator refers the member to the Texas Workforce Solutions-Vocational Rehabilitation Services (TWS-VRS) within 30 days of meeting with a member and identifying an interest in obtaining employment. The service coordinator should contact the local TWC office to identify the referral process used by that office. Local TWC offices may be located at webp.twc.state.tx.us/services/VRLookup/.

A member who made contact with TWS-VRS is eligible to receive EA through MDCP until TRS-VRS has developed the Individualized Plan of Employment (IPE) and the member has signed it. If a member refuses to contact TWC, they may not receive waiver-funded EA. 

If the member has exhausted TRS-VRS services or been determined ineligible for TRS-VRS services, the service coordinator authorizes a minimum of 10 hours for employment on the member's individual service plan (ISP). EA can be authorized up to 180 days. The member or provider may request more hours for EA, if needed, and funds are available in the member's MDCP budget.

If, after making application with TWS-VRS, the member is determined ineligible for TWS-VRS services, EA through MDCP can continue until the member obtains competitive integrated employment.

4911 Coordination with Texas Workforce Solutions-Vocational Rehabilitation Services for Employment Assistance

Revision 22-3; Effective Dec. 1, 2022

Upon request and with proper authorization for disclosure, the service coordinator helps the member provide the Texas Workforce Solutions-Vocational Rehabilitation Services (TWS-VRS) Vocational Rehabilitation Counselor (VRC) with the following items from a member:

• photo identification;
• an original Social Security card;
• member's home address and mailing address;
• names and addresses of any doctors the member has seen recently;
• names and addresses of any schools the member has attended;
• information about the member's medical insurance;
• a list of places the member has worked, including type of job, dates, the reason for leaving and salary;
• proof of income for the member and their spouse, or parents (if the parents claim the member as a dependent on their income tax);
• proof of expenses related to monthly mortgage or rental payments, debts imposed by court order, personal medical costs and other disability-related expenses;
• names, addresses and phone numbers of two people who will know how to contact the member;
• any reports of recent medical exams, school records or other information that may help the VRC understand the member's disability;
• member's most recent service plan;
• any current vocational assessments or person-directed plans that focus on employment opportunities;
• any other available records pertaining to the member's disabilities, including but not limited to medical, psychological and psychiatric reports;
• a copy of the member's court-ordered guardianship documents, if any guardian has been appointed; and
• contact information for the member's service coordinator.

TWS-VRS will:

• notify a member in writing if the member is determined to be eligible or ineligible for TWS-VRS services;
• notify a member in writing when the member’s TWS-VRS case is closed;
• develop with the eligible member an Individualized Plan for Employment (IPE) within 90 days of determination of eligibility for services;
• After the IPE is completed, begin coordinating the provision of services as identified on the IPE; and
• Upon request and with proper authorization for disclosure, provide copies of any of the member's records to the service coordinator, including the following documents:
  • a completed copy of the member's application statement;
  • a member's completed IPE;
  • written documentation specifying a member's eligibility status; and
  • the notification letter indicating TWS-VRS is completed.

If TWS-VRS has not notified the member of an eligibility decision within 60 days of the initial TWS-VRS appointment, the member's service coordinator attempts to contact the assigned TWS-VRS VRC to determine the status of the application and document the contact in the narrative notes.

The member's service coordinator will ensure that communication is maintained with the assigned TWS-VRS VRC about waiver-funded services provided between the Vocational Rehabilitation (VR) referral and the "start date" of TWS-VRS active services, as defined in the individual's TWS-VRS VR IPE.

At the request of a member determined eligible for TWC, the service coordinator, will assist the member if possible, and:

• participate in TWS-VRS planning meetings related to the member's employment, or ensure other individuals important to the member attend, as appropriate;
• take an active role in providing input to the TWC IPE, or ensure other individuals important to the member provide input, as appropriate; and
• if long-term services and supports are needed to maintain or advance in employment, supported employment will be incorporated in a revision to the member's service plan when the member reaches “Job Stability” status with TWS-VRS.

The member's provider must begin providing or subcontracting for those services and supports approved in the member's service plan without a gap between the provision of TWS-VRS and waiver services.

4912 Employment Assistance Providers

Revision 22-2; Effective September 1, 2022

Employment assistance providers are either employed by a licensed Home and Community Support Services Agency (HCSSA), also called a home health agency, or are employed by a member or their legally authorized representative under the Consumer Directed Services (CDS) option. At a minimum, the employment assistance provider must be at least 18 years of age, maintain a current driver license and insurance if transporting the individual, and satisfy one of these options:

Option 1:

• A bachelor's degree in rehabilitation, business, marketing, or a related human services field; and
• Six months of paid or unpaid experience providing services to people with disabilities.

Option 2:

• An associate's degree in rehabilitation, business, marketing, or a related human services field; and
• One year of paid or unpaid experience providing services to people with disabilities.

Option 3:

• A high school diploma or Certificate of High School Equivalency (GED credentials); and
• Two years of paid or unpaid experience providing services to people with disabilities.

Under the CDS option, the provider cannot be the member's legal guardian or the spouse of the legal guardian.

4920 Supported Employment

Revision 22-3; Effective Dec. 1, 2022

Supported employment (SE) services help a member receiving Medically Dependent Children Program (MDCP) services sustain competitive employment or self-employment.

SE services include:

• assistance provided to a member to sustain competitive employment and who, because of a disability, requires intensive, ongoing support to be self-employed, work from home or perform in a work setting where individuals without disabilities are employed;
• employment adaptations, supervision and training related to a member's assessed need; and
• ensuring members earn at least minimum wage, if not self-employed.

Competitive employment is work:

• in the competitive labor market where anyone may compete for employment that is performed on a full-time or part-time basis in an integrated setting; and
• where a member is compensated at or above the minimum wage, but not less than the customary wage and level of benefits paid by the employer for the same or similar work performed by individuals without disabilities.

An integrated setting is a setting typically found in the community where members interact with people without disabilities, other than service providers, to the same extent that people without disabilities in comparable positions interact with other people without disabilities. An integrated setting does not include a setting where:

• groups of people with disabilities work in an area not part of the general workplace where people without disabilities work; or
• a mobile crew of people with disabilities work in the community.

An MDCP member may seek SE to aid the member in maintaining self-employment. Self-employment is work that the member:

• solely owns, manages and operates a business;
• is not an employee of another person, entity or business; and
• actively markets a service or product to potential customers.

SE may only be authorized through the MDCP waiver if documentation is maintained in the member's record that the service is not available to the member under a program funded under the Individuals with Disabilities Education Act (20 U.S.C. Section 1401 et seq.).  In the state of Texas, this service is not available to individuals under a program funded under section 110 of the Rehabilitation Act of 1973.

4921 Coordination with Texas Workforce Commission for Supported Employment

Revision 19-1; Effective June 3, 2019

The service coordinator coordinates with the Texas Workforce Commission (TWC) and the local school districts, seeking third party resources before using Medically Dependent Children Program (MDCP) employment services, including school districts.

Activities include:

• devoting time during a member's initial service planning meeting to discuss employment with the member and family and the process to obtain employment services and supports;
• making a referral to TWC, assisting with completing the application form, and documenting the referral and outcome of the referral in the member's case record;
• continuing to explore the possibility of employment at subsequent service planning meetings for a member who is not employed in the community;
• affirming or explaining how a member can work and still maintain current medical benefits (e.g., through the Medicaid Buy-In program), and in most cases will have an increase in income;
• explaining rights to appeal if services are denied, reduced or terminated; and
• monitoring whether the member and family are satisfied with the employment supports.

4922 Supported Employment Providers

Revision 22-2; Effective September 1, 2022

Supported employment (SE) providers are either employed by a licensed Home and Community Support Services Agency (HCSSA), also called a home health agency, or are employed by a member or their legally authorized representative under the Consumer Directed Services (CDS) option. As a minimum, the SE provider must be at least 18 years of age, maintain a current driver license and insurance if transporting individual, and satisfy one of these options:

Option 1:

• A bachelor's degree in rehabilitation, business, marketing, or a related human services field; and
• Six months of paid or unpaid experience providing services to people with disabilities.

Option 2:

• An associate's degree in rehabilitation, business, marketing, or a related human services field; and
• One year of paid or unpaid experience providing services to people with disabilities.

Option 3:

• A high school diploma or Certificate of High School Equivalency (GED credentials), and
• Two years of paid or unpaid experience providing services to people with disabilities.

Under CDS, the provider cannot be the member's legal guardian or the spouse of the legal guardian.