2100, Case Management

2110 Description of Case Management

Revision 17-1; Effective March 15, 2017

40 Texas Administrative Code §48.2917 — Clients must meet the eligibility criteria for CCSE services, but they do not have to receive services to receive case management. Ineligible applicants receiving only information and referral are not eligible for case management.

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

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

Case management also includes:

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

Nine is the lowest score an individual can have and still qualify for a Community Care for Aged and Disabled service on the basis of his score on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide. An individual must score at least nine on Form 2060 to be eligible for case management only.

2120 Case Management Process

Revision 17-1; Effective March 15, 2017

Case management involves six individual functions.

  1. Intake — Requests for service or information are made by an individual, or someone on the individual's behalf, by telephone, letter or in person. Texas Health and Human Services Commission (HHSC) intake staff:
    • determine exactly what is being requested;
    • record certain information given by the requester;
    • give the requester certain information;
    • determine whether an immediate, expedited or routine response is necessary; and
    • refer the request to the appropriate unit for further action.

For detailed intake procedures, see 2200, Intake Procedures.

  1. Assessment — HHSC case workers respond to intake by visiting the person at home or other setting to conduct a face-to-face assessment of eligibility and needs. The assessment process includes:
    • determining financial eligibility;
    • determining functional eligibility relative to performance of activities of daily living;
    • assessing the individual's home, social/environmental supports and resources;
    • determining services the individual needs and whether those needs are currently being met by family or community resources; and
    • assessing the individual's physical condition and determining whether that condition, in combination with the environment, poses any degree of risk.

For detailed assessment procedures, see 2400, Assessment Process.

  1. Service planning — After completing the assessment, case workers develop a service plan with each eligible individual. Service planning includes:
    • determining what services and environmental adaptations are required to satisfy the individual's personal unmet needs, health and safety;
    • determining and specifying what services will be secured from whom or from where, how much will be provided and on what schedule;
    • specifying how often the case worker will monitor the provision of services and individual satisfaction; and
    • obtaining the individual's concurrence with the service plan.

For detailed service planning procedures, see 2500, Service Planning.

  1. Service authorization
    1. Non-Medicaid services — If non-Medicaid HHSC services are to be purchased as part of the service plan, the case worker:
      • authorizes the services according to program policies and procedures;
      • sends the service plan and individual referral information to the provider selected by the individual; and
      • discusses the plan with the potential provider, as necessary.
    2. Medicaid services — If Medicaid services are to be purchased as part of the service plan, the case worker:
      • designates the services according to Medicaid program policies and procedures;
      • obtains, if necessary, consultation from the regional nurse regarding medical need for services;
      • sends the service plan and individual referral information to the provider selected by the individual;
      • discusses the plan with the provider supervisor, if requested; and
      • discusses the plan with the regional nurse, as necessary.

For detailed service authorization procedures, see 2600, Authorizing and Reassessing Services.

  1. Service monitoring and evaluation — The case worker:
    • contacts each individual after service referral, according to case management requirements, to ensure that services were initiated as scheduled and to determine the individual's satisfaction with the service;
    • contacts and visits each individual according to the individualized case management plan or upon request by the individual or others;
    • accompanies regional nurses on utilization review home visits, when requested;
    • evaluates the individual's condition, needs and service provision on an ongoing basis, according to HHSC procedures and individual requirements;
    • requests consultation and joint home visits with the regional nurse or provider nurse, or both, when indicated because of the individual's health condition or risk status;
    • receives information from providers about the individual's ongoing needs and conditions; and
    • reassesses individual's needs and reviews and reauthorizes service plans according to required schedules.

For detailed procedures concerning service monitoring, see 2700, Service Monitoring, Changes and Transfers.

  1. The case worker is also responsible for assisting individuals who have lost their Your Texas Benefits (YTB) Medicaid card or never received it. For detailed procedures, see 2130, Your Texas Benefits Medicaid Card and Replacement.

2130 Your Texas Benefits Medicaid Card and Replacement

Revision 17-1; Effective March 15, 2017

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

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

The individual may call 1-855-827-3748 if the card is lost and the individual needs a replacement card. Medicaid providers and pharmacies can verify eligibility by phone using a provider-dedicated line, so even if a card is lost, the Medicaid recipient can receive services or fill a prescription. The card should not be thrown away, even if the recipient is denied Medicaid, since the card will be reused if the individual later regains eligibility.

Requesting Form H1027-A, Medicaid Eligibility Verification

Form H1027-A, Medicaid Eligibility Verification, is a secure form, not available on the website and must be ordered. However, the form instructions are available on the Texas Health and Human Services Forms website for completion of the form. Designated HHSC staff may continue to assist individuals in the following situations:

  • Ongoing Medicaid Recipients — HHSC staff may assist with a manual Form H1027-A upon request because the recipient either lost the YTB Medicaid card or did not receive it. HHSC staff issuing Form H1027-A should inform the recipient of the following:
    • Call 1-855-827-3748 for a replacement card.
    • The burden of verifying Medicaid eligibility is with the provider. An individual who is Medicaid eligible, but does not have written proof of eligibility, should still be able to get services from his provider or to fill a prescription. Medicaid providers and pharmacies can verify eligibility by phone using a provider-dedicated line or by using the Texas Medicaid & Healthcare Partnership (TMHP) TexMedConnect website.
  • New Medicaid Recipients — Eligibility information is not immediately available for providers/pharmacies to verify after Medicaid is approved. HHSC staff must refer the recipient to the HHSC Benefits office to issue Form H1027-A between the time the eligibility is determined and the time the eligibility is available in the on-line system.

Once the recipient receives the replacement card, he presents it to the Medicaid provider or pharmacy any time services are requested. The recipient may call 1-800-252-8263 or 2-1-1 to confirm Medicaid coverage if he is not sure of his eligibility status.

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