Section 10000, State Plan Long Term Services and Supports

Revision 20-1; Effective March 16, 2020

 

 

10100 Long Term Services and Supports

Revision 17-5; Effective September 1, 2017

 

Texas Medicaid offers an array of long term services and supports (LTSS) to STAR+PLUS members. Managed care organizations (MCOs) authorize LTSS in a way that reflects a member's ongoing need, based on a person-centered assessment, and a person-centered service plan. State plan LTSS are available to all STAR+PLUS members who meet functional and/or medical necessity for the services. Services include Day Activity and Health Services (DAHS), Personal Assistance Services (PAS), Community First Choice (CFC) for members who meet Level of Care eligibility, and services provided by a nursing facility.

 

10110 Day Activity and Health Services

Revision 17-5; Effective September 1, 2017

 

Day Activity and Health Services (DAHS) is a Medicaid state plan service available to STAR+PLUS members who may benefit from a structured and comprehensive program that is designed to meet the needs of adults with functional impairments through an individual plan of care by providing health, social and related support services in a protective setting. Eligibility for the service is limited to members who need the service because of a chronic medical condition and are able to benefit therapeutically from the service. DAHS provides services in a facility setting, under the supervision of a nurse. Services include nursing and nurse-delegated tasks, physical rehabilitation, nutrition, social activities and transportation to and from the facility when another means of transportation is unavailable.

 

10111 Limitations

Revision 17-5; Effective September 1, 2017

 

Day Activity and Health Services (DAHS) is limited to no more than 10 hours per day and 230 hours per month, per the Medicaid State Plan, and is typically authorized for three to six hours per day. This limit may be exceeded with additional authorization from the managed care organization (MCO). Authorization for DAHS must be related to the member's chronic medical condition to be considered medically necessary and the member must have one or more functional limitations and a physician assessment indicating the potential for receiving therapeutic benefit from DAHS. Authorization relating to a primary diagnosis of mental health disorders, intellectual disabilities or related conditions is prohibited by the State Plan.

 

10120 Day Activity and Health Services Providers

Revision 17-5; Effective September 1, 2017

 

Day Activity and Health Services (DAHS) is provided in a Texas Health and Human Services System licensed facility and in the community. To provide DAHS, a facility must hold a current license, be credentialed and monitored by the managed care organization (MCO), and hold an MCO contract.

DAHS facilities are responsible for:

 

10130 Assessment for Day Activity and Health Services

Revision 17-5; Effective September 1, 2017

 

The potential for therapeutic benefit must be established by a physician's assessment and requires a physician's order. Functional need for Day Activity and Health Services (DAHS) is established by the managed care organization (MCO) service coordinator using Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, and Form H2060-A, Addendum to Form H2060, or Form H6516, Community First Choice Assessment, and Form H2060-A.

A DAHS facility nurse must complete a DAHS assessment or the MCO's equivalent process for each STAR+PLUS member at the facility. The DAHS assessment or equivalent process may be conducted by the facility nurse, based upon the member's condition at the time of initial assessment. The DAHS facility nurse completes a DAHS assessment or the MCO's equivalent process at either the facility or the member's home. DAHS assessments must be conducted, at minimum, when:

 

10140 Reassessment for Day Activity and Health Services

Revision 17-5; Effective September 1, 2017

 

Reassessment for Day Activity and Health Services (DAHS) by a physician is required at least every 12 months for continued authorization. Reassessment of functional and medical necessity for DAHS is established, at least annually, by the managed care organization (MCO) service coordinator using:

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:

 

10150 Authorization for Day Activity and Health Services

Revision 20-1; Effective March 16, 2020

 

To authorize Day Activity and Health Services (DAHS), the managed care organization (MCO) must obtain a physician’s assessment and complete the following forms:

The documentation required by the MCO must be dated no more than 90 days prior to the authorization request. MCOs may issue temporary authorizations if the physician’s assessment and all forms are not submitted. Temporary authorizations are valid for at least 30 days but will expire after 60 days.  Authorizations should be updated when the member is assessed by their physician and all forms are submitted to align with the 90-day time frame between the date of assessment and authorization.

DAHS authorizations must reflect the member's ongoing needs and should typically be valid for 12 months, unless the member experiences a significant change in condition or is admitted to a hospital or nursing facility, transfers between facilities or transfers to a new MCO. If an authorization is issued for less than 12 months, the MCO may not require a new physician’s assessment unless the member experiences a change in condition, as described in the STAR+PLUS contract(s) regarding assessment instruments, or if the change is related to changes in dietary restrictions, medications, transportation needs or other services provided by the facility.

 

10160 Reauthorization of Day Activity and Health Services

Revision 20-1; Effective March 16, 2020

 

Providers of Day Activity and Health Services (DAHS) must receive reauthorization from a managed care organization (MCO) at least every 12 months in accordance with the Texas Medicaid state plan. If a member transfers to a different facility, a new authorization from the gaining facility must be obtained prior to delivery of service. Failure to obtain an authorization may result in non-payment or recoupment.

If a member experiences a significant change in condition or is admitted to a hospital, they may need a new physician’s assessment. The DAHS facility assessment (Form 3050, DAHS Health Assessment/Individual Service Plan, or the MCO’s equivalent) and the physician’s assessment must be updated based on the member's current condition.

If the member's physician's assessment, dietary and medication needs, and functional ability have not changed since the previous DAHS authorization, the physician may use an abbreviated form for the physician’s assessment, if permitted by the MCO. An MCO may permit the physician’s assessment to be kept on file with the provider, rather than submitted to the MCO, if the MCO conducts periodic audits of provider files.  

MCOs may issue temporary reauthorizations if the physician’s assessment and all forms are not prepared or submitted at the same time. Temporary reauthorizations expire 60 days from receipt by the facility. Reauthorizations may be sought at any time. The reauthorization must not exceed a period of 12 months.

 

10170 Transfer Between Facilities

Revision 17-5; Effective September 1, 2017

 

If a member chooses to transfer to a different Day Activity and Health Services (DAHS) facility in the same area or moves to another part of the state, the gaining facility must complete an assessment and obtain the managed care organization’s (MCO's) required documentation within 14 days for continued authorization. If the gaining facility cannot obtain required documentation within 14 days, the MCO may issue a temporary authorization to ensure continuity of care. The MCO may not require a new physician assessment if an assessment was conducted in the previous 12 months. The gaining facility should request documentation pertaining to the member, including assessments and forms from the member's former facility or the member's MCO service coordinator.

 

10180 Transfer Between MCOs

Revision 17-5; Effective September 1, 2017

 

 

 

10181 New MCO Same Service Area

Revision 17-5; Effective September 1, 2017

 

If a member transfers managed care organizations (MCOs) in the same service area, the existing authorization for Day Activity and Health Services must be honored until the earliest of the following actions:

 

10182 New MCO Different Service Area

Revision 17-5; Effective September 1, 2017

 

If a member moves to a different service area and a different managed care organization (MCO) and has an existing authorization for Day Activity and Health Services (DAHS), the new MCO must assist the member in locating an in-network DAHS facility and primary care provider. The new MCO must complete required forms (Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, and Form H2060-A, Addendum to Form H2060, or Form H6516, Community First Choice Assessment, and Form H2060-A). The new facility must work with the new MCO to complete the MCO's required documents and forms.