2600, Authorizing and Reassessing Services

2610 Application Processing and Notification

Revision 17-1; Effective March 15, 2017

40 Texas Administrative Code §48.3901(d) — Eligibility for CCSE services for income-eligible applicants is determined within 30 calendar days after a signed application is received. For categorically-eligible applicants, eligibility must be determined within 30 calendar days after either the consumer's assessment or face-to-face contact with the worker, whichever occurs first. If the applicant withdraws from the program before an assessment is completed or a face-to-face interview is conducted, no further action is necessary.

 

2611 Processing Time Frames

Revision 17-1; Effective March 15, 2017

Program Standard: The case worker is required to determine eligibility for Community Care Services Eligibility (CCSE) services for income-eligible applicants as soon as possible, but within 30 calendar days after a signed application is received. The case worker must determine eligibility for categorically eligible applicants as soon as possible, but within 30 calendar days after either the individual's assessment or face-to-face contact with the case worker, whichever occurs first.

This standard is applied to all applications, except for Community Attendant Services (CAS), using the date shown in "Date Eligibility Rules Processed" on the Service Authorization System Online Wizards (SASOW) Form 2064, Eligibility Worksheet, as the end point of measurement. The 30-day processing deadline cannot be used to unnecessarily delay a decision if all information is available before the 30th calendar day.

Proceed with the eligibility determination process if the individual fails to cooperate but has received facility-initiated Day Activity and Health Services (DAHS) as a Medicaid individual. See the procedures in Section 4231.2, Intake Response.

 

2611.1 Processing Time Frames for Community Attendant Services

Revision 17-1; Effective March 15, 2017

Applications for Community Attendant Services (CAS) must be referred to Medicaid for the Elderly and People with Disabilities (MEPD) staff for a financial eligibility determination. Because the MEPD process can take up to 45 days for regular referrals and 90 days if a disability determination is required, this may delay Community Care Services Eligibility (CCSE) certification beyond the 30-day time frame.

MEPD will notify the Texas Health and Human Services Commission (HHSC) case worker of the eligibility decision through the MEPD to HHS Communication Tool. However, if a decision is not received, the HHSC case worker must check the Texas Integrated and Eligibility Redesign System (TIERS) for an MEPD eligibility decision on or before the 25th day from the application date and perform weekly checks until the eligibility decision is received. The TIERS checks must be documented in the case record.

When the eligibility decision notification is received either through TIERS or the MEPD to HHS Communication Tool, the case worker has seven business days to:

  • complete data entry in the Service Authorization System Online Wizards (SASOW); and
  • send the referral packet to the Home and Community Support Services Agency (HCSSA) to begin pre-initiation activities.

The seven business days are measured from the date HHSC receives the eligibility decision from MEPD or the date eligibility is verified through TIERS. The case worker must print a copy of the eligibility notice or TIERS screen and file it in the case record.

The HHSC case worker must advise MEPD only if the applicant is not approved for CAS (i.e., no practitioner’s statement or other circumstances preventing services delivery). In this circumstance, the case worker must send Form H1746-A,  MEPD Referral Cover Sheet, to MEPD within two business days of determining the individual is not eligible for CAS, advising that the applicant has not met the functional eligibility requirements. Form H1746-A is sent to MEPD at the same time Form 2065-A, Notification of Community Care Services, is sent to the individual notifying him of CAS ineligibility.

The case worker is not required to notify MEPD when CAS services are authorized.

See Section 4653, Referral to the Provider, and Section 4660, Service Authorization, for additional procedures for authorizing CAS services.

Case workers always have seven business days after confirmation of MEPD eligibility to send the referral to the provider. This applies even when verification of MEPD certification is received near the end of the 30-day period allowed for completing CCSE applications.

 

2612 Notification of Eligibility Decision

Revision 17-1; Effective March 15, 2017

An applicant/individual certified for one Community Care Services Eligibility (CCSE) service but determined ineligible for another must be notified in writing of both decisions. An applicant/individual certified for personal attendant services and/or Home-Delivered Meals must also be notified in writing of the units per week he is eligible to receive services. If certified for Day Activity and Health Services (DAHS), the applicant/individual must be notified in writing of the number of days per week the DAHS authorization covers. The written notice for all services must contain the case worker's name, telephone number and appeal procedures.

When notifying the applicant of eligibility, specify on Form 2065-A, Notification of Community Care Services:

  • the CCSE services for which the applicant is eligible or ineligible, and
  • if determined eligible:
    • the number of hours of services the applicant is authorized to receive or the number of days or half days the applicant is authorized to attend a DAHS facility;
    • if applicable, that the Family Care or Primary Home Care applicant is eligible for priority status; and
    • the initial and ongoing copayments the Residential Care individual is to pay to the facility.

The case worker may notify an individual verbally of continued eligibility if the individual continues to qualify for the same service(s) and the number of hours/units of service remains the same. Document in the individual's case record the date the case worker verbally informed the individual of his continued eligibility.

See Section 2662, Redetermination of Financial Eligibility, and Section 2660, Reassessments and Recertification Procedures, for time limits that apply when eligibility is redetermined.

 

2613 Case Record Documentation

Revision 21-4; Effective December 1, 2021

To document the eligibility decision, the applicant’s case record must contain signed and dated copies of the following forms:

  • Form 2064, Eligibility Worksheet, except if;
    • the application is denied before a financial eligibility determination is made; and
  • Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, except if the;
    • applicant requested only Day Activity and Health Services (DAHS), which does not require a Form 2060 score;
    • applicant withdrew the application before the case worker completed Form 2060;
    • application is denied for a reason other than:
      • no unmet need;
      • insufficient functional impairment; or
      • low hours for Family Care or Primary Home Care.

Note: Ensure each person enrolled in a Title XX program who is not categorically financially eligible receives a privacy notice, Form 0401, Notice of Privacy Practices or Form 0403, Explanation to Health Information Privacy Rights, as appropriate. 

Related Policy 

Privacy Notice, 1147

 

2620 Service Authorizations

Revision 21-2; Effective June 1, 2021

After developing the service plan with an eligible person, enter information in the Service Authorization System Online Wizards (SASOW) to authorize services.

Service plans may include one or more purchased services. If authorizing more than one service, ensure the tasks are not duplicative and the service combinations do not exceed the allowable costs specified in Appendix II, Cost Limit for Purchased Services.

Example: Before authorizing 10 units of Day Activity and Health Services (DAHS) per week for a person who will also be receiving an in-home service, determine if it is feasible for the person to take part in DAHS five full days per week.

Based on the urgency of the person’s need, negotiate with the provider for the earliest possible date that services can begin. Remember that services can and may need to begin on the weekend if discharging a person from a hospital or other institution on a Friday afternoon and needs services immediately. Enter the negotiated beginning date of coverage.

Use the comments section of Form 2101, Authorization for Community Care Services, to give specific instructions to the provider about the person’s service arrangement. These include the number of days the person requests services, specific service schedules that are required or strongly preferred by the person, specific instructions about unique personal problems or the person’s home, or information about people who should not be hired as the paid attendant.

For all personal attendant services (PAS), send the provider the initial packet which must include a cover sheet, the Long-term Care Services Intake System (NTK) generated Form 2110, Community Care Intake, and a copy of the following SASOW generated forms:

  • Form 2059, Summary of Client’s Need for Service;
  • Provider Referral Supplement;
  • Form 2060, Needs Assessment Questionnaire and Task/Hour Guide;
  • Task/Hour Guide; and
  • Form 2101, Authorization for Community Care Services.

Note: In the SASOW, the following forms are generated as two forms:

  • Form 2059 is generated as Form 2059 and the Provider Referral Supplement.
  • Form 2060 is generated as Form 2060 and the Task/Hour Guide.

For Family Care, the Form 2101 is an authorization to begin services.

For CAS and PHC, the Form 2101 is a referral and authorization for services is left pending for receipt of Form 3052, Practitioner’s Statement of Medical Need.  

Providers must follow the instructions on Form 2101. If a provider does not, try to resolve the problem through discussion with the provider’s supervisors. If this fails, document and report the problem to your supervisor and follow the procedures specified in Section 2700, Service Monitoring, Changes and Transfers.

Related Policy

Content of Referral Packets, Appendix XIII

 

2630 Referrals to the Provider

Revision 17-1; Effective March 15, 2017

Refer to Section 4000, Specific CCSE Services, for specific procedures for each service for sending referrals to providers. See Appendix XIII, Content of Referral Packets, for referral-packet contents sent to providers for each service.

 

2631 Negotiated Referrals

Revision 17-11; Effective November 20, 2017

Program Standard: Individuals must be referred no later than the next business day after the day the individual is visited and/or it is determined that a negotiated verbal referral is necessary. Form 2101, Authorization for Community Care Services, must be sent within five business days from the date the individual was determined eligible for a negotiated verbal referral. Use the comment section of the form to document verbal referrals, dates and other relevant information. The case worker must document in the case file the date Form 2101 was sent to the provider either in the narrative or by including the fax confirmation.

Regardless of the response criteria established for the applicant at intake, the case worker must reassess the individual's need for service initiation during the assessment process. In particular, assess the continued provision of any assistance with the individual's personal care needs by individuals and/or other providers.

If it is determined that the individual's unmet needs for personal care are, or will be, such that services must begin sooner than the time usually required when using the routine written referral process, contact the provider and negotiate a start date according to the individual's need for service initiation. The need for a verbal referral will vary from individual to individual. Consult with the unit supervisor if an individual's particular circumstances are such that it is uncertain whether to use the negotiated referral process.

 

2632 Routine Referrals

Revision 17-11; Effective November 20, 2017

Program Standard: For applicants who do not require negotiated referrals, authorize services by sending Form 2101, Authorization for Community Care Services, within five business days from the date the applicant is determined eligible. The case worker must document in the case file the date Form 2101 was sent to the provider either in the narrative or by including the fax confirmation.

If a provider is operating at capacity, or if all budgeted service slots are filled when an eligible individual is referred for services, enter the individual's name on the appropriate interest list. Individuals must be served as indicated in Section 2230, Interest List Procedures. For services other than Day Activity and Health Services (DAHS), Community Attendant Services (CAS) and Primary Home Care (PHC), the provider must return Form 2101 by the 21st calendar day from the date of the referral. If Form 2101 or some other kind of notification is not received, contact the provider to find out the reason for the delay and the status of the referral.

If the provider is unable or fails to provide services within the negotiated time, refer the individual to another provider. If another provider cannot provide the services as needed, resolve the problem through conference with the supervisor. For special referral procedures for PHC, CAS and DAHS, see Section 4000, Specific CCSE Services.

 

2640 Provider Requirements for Hiring a Paid Attendant

Revision 20-3; Effective September 1, 2020

Criminal background checks are required for all facilities and service providers who provide care to the aged and disabled. Except in emergency situations, providers are required to obtain a criminal history check before offering permanent employment to unlicensed employees having direct contact with recipients who receive:

  • Day Activity and Health Services;
  • Residential Care;
  • Primary Home Care;
  • Adult Foster Care; or
  • Client-Managed Attendant Care.

A person must be barred from employment if they have been convicted of a criminal offense where an administrative review is not available. A person may request an administrative review for some criminal offenses that could bar employment.

If asked by anyone, including the recipient, about the results of the criminal history check, explain that:

  • all providers must conduct criminal history checks on attendants;
  • the Texas Health and Human Services Commission (HHSC) is monitoring compliance with the law; and
  • confidentiality requirements prevent sharing information obtained as a result of a criminal history check with anyone except the employee.

 

2650 Changes in Service Plans

Revision 17-1; Effective March 15, 2017

 

2651 Disagreements about Service Plans

Revision 17-1; Effective March 15, 2017

If a disagreement arises between provider staff and Texas Health and Human Services Commission (HHSC) staff about an individual's service plan, resolve the problem through discussion and negotiation. Use an interdisciplinary meeting, if necessary. Ensure that services are not delayed unnecessarily because of these disagreements.

HHSC regional nurses make final decisions in disagreements with providers about an individual's medical need for Community Attendant Services and Day Activity and Health Services.

In all other instances, the Community Care Services Eligibility (CCSE) supervisor attempts to resolve the disagreement with the provider's supervisor. If supervisory staff of both providers are unable to resolve the disagreement, the CCSE program manager resolves the disagreement.

 

2652 Changing the Service Schedule Between Reassessments

Revision 17-1; Effective March 15, 2017

If a schedule change results in a change in hours or priority status, use the chart below to determine which specific changes must be included on Form 2101, Authorization for Community Care Services.

Type of Individual Specific Instructions
Ongoing Primary Home Care or Community Attendant Services with chronic medical conditions, and transfer individuals Specify the effective date as the beginning date of the service plan change on Form 2101, Item 4. If the change results in:

 

  • an increase in hours, the "Begin" date on Form 2101 must be at least seven days from the Form 2101 date, unless another date is negotiated; or
  • a reduction in hours, the "Begin" date on Form 2101 must be at least 12 days from the Form 2101 date. See Appendix XXIII, Form 2101 Coverage Dates for Title XIX Services, for additional information.

    Note: For a reduction in hours, the "Begin" date on Form 2101 must match the effective date on Form 2065-A, Notification of Community Care Services.
Community Attendant Services If a change is being conducted in conjunction with an annual reassessment, enter the "Begin" date as indicated below and leave the authorization "Pending." The HHSC nurse will authorize Form 2101.

If a decrease in service is being implemented between assessment periods, the "Begin" date should be 12 days in the future to allow advance notice of the reduction in service. The "Begin" date must match the effective date on Form 2065-A.

For an increase in hours, the "Begin" date should be dated seven days in the future to allow the provider time to implement the change, unless a different date has been negotiated.

Family Care and Family Care transfer case The "Begin" date should be 12 days in the future to allow advance notice of the reduction in service.

 

For an increase in hours, the "Begin" date should be dated seven days in the future to allow the provider time to implement the change, unless a different date has been negotiated.

For all other changes not related to a change in hours, complete Form 2067, Case Information, for personal attendant services.

 

2653 Provider Flexibility

Revision 17-1; Effective March 15, 2017

Providers are, as much as possible, expected to follow instructions given on Form 2101, Authorization for Community Care Services. However, there are times when changes in tasks or schedules will be necessary in order to meet the individual's needs. In these situations, it is not necessary for the provider to notify the case worker as long as the units delivered and billed for a calendar month do not exceed 4.33 times the adjusted weekly hours identified on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide.

Example – An individual who regularly receives 15 hours of service per week is sick for two days and declines services due to illness. During those two days, a total of five hours of personal care services would have been delivered had the individual been able to receive services. Because the individual may have an increased need for services following the illness, those five hours may be made up if it would be to the benefit of the individual. Because the number of hours delivered does not exceed the number of hours authorized, the provider does not need to notify the case worker.

This ongoing flexibility is intended to allow services to meet the individual's needs, considering his desires and changes in his condition. The flexibility is not intended to be for the convenience of the provider or to be applied retroactively to justify an attendant absence or interruption of services.

If a provider makes changes to tasks/schedules inappropriately or against the individual's wishes, try to resolve the problem through discussions with a provider supervisor. If this fails, report the problem to the case worker's supervisor and follow procedures specified in Section 2700, Service Monitoring, Changes and Transfers.

 

2660 Reassessments and Recertification Procedures

Revision 18-1; Effective June 15, 2018

Conduct reassessments and (if applicable) referrals of individuals to Community Care Services Eligibility (CCSE) services within:

  • 24 months of the last financial redetermination, and
  • 12 months of the last functional assessment.

Annual reassessments are required for all CCSE services. See Section 2663.1, Annual Home Visit Required for Individuals Receiving PAS, and Section 2663.2, Determining When a Home Visit is Necessary for Other Services, to determine if a home visit is required for the reassessment.

When the reassessment is conducted in the individual's home, the case worker must schedule the visit with the individual or his authorized representative at a time that is convenient to the individual. Schedule the appointment by telephone or in writing using Form 2068, Application, Redetermination or Monitoring for Community Care Services. If the appointment cannot be kept for some reason, inform the individual or his authorized representative in advance that the appointment will have to be rescheduled. Do not visit the individual without advance notice of the visit.

During the reassessment, the case worker must:

  • redetermine functional eligibility on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, as required by the specific program;
  • redetermine unmet need, as outlined in Section 2433, Determining Unmet Need in the Service Arrangement Column;
  • present the Consumer Directed Services (CDS) option and have the individual sign Form 1581, Consumer Directed Services (CDS) Option Overview; and
  • present Form H0025, HHSC Application for Voter Registration, and offer the opportunity to register to vote

To comply with the National Voter Registration Act of 1993, the individual must be offered the opportunity to register to vote at the time of application and at each annual redetermination. Provide assistance to any individual who requests assistance in completing Form H0025, Review Form H0025 for completeness in the individual's presence. The individual may:

  • mail Form H0025; or
  • return the form to the case worker's office for appropriate mailing to the county registrar's office.

 

2661 Individual Unavailable for Reassessment

Revision 17-1; Effective March 15, 2017

In some situations, the case worker will use his judgment to determine how long a case should remain open when the individual is unavailable for a reassessment. As a general rule, if the individual continues to be unavailable for more than 30 days, it should be determined if the unavailability is temporary. If an individual is repeatedly unavailable after an appointment has been scheduled, refer to the procedures in Section 2830, Refusal to Comply with Service Delivery Provisions. If the individual is unavailable because of temporary nursing home admission, use the time limits and procedures in Section 2822, Service Suspension by Case Workers.

 

2661.1 Delay in Home Visits Due to Individual Illness

Revision 17-1; Effective March 15, 2017

While it is important that required home visits are performed on a timely basis, due to the increase in serious transmittable diseases in the general population, there may be circumstances that could place staff at risk for contracting contagious illnesses.

In order to ensure the health and welfare of staff members who could come in contact with individuals reporting a contagious illness, case workers may delay home visits under the following circumstances.

If a case worker contacts an applicant/individual to schedule a home visit (initial, reassessment or monitoring visit) and the individual states he has a contagious illness such as influenza, the case worker must document the contact and the reason for the delay of the home visit, including the stated illness. If possible, the case worker should schedule a future date for the visit when the individual thinks he will be better. If unable to schedule the visit for a future date, the case worker must contact the individual at least weekly until the home visit can be made. Each contact must be documented in the case record. This documentation will be considered as an acceptable reason for delaying a required home visit.

 

2662 Redetermination of Financial Eligibility

Revision 18-1; Effective June 15, 2018

Program Standard: The case worker must redetermine financial eligibility within 24 months of the previous determination of financial eligibility.

The financial reassessment must be completed by the last day of the 24th calendar month from the previous financial redetermination. To redetermine financial eligibility for income-eligible individuals, use the policies and procedures in Section 3000, Eligibility for Services. The case worker must:

  • compare income and resources reported this year with what was previously reported;
  • discuss with the individual any discrepancies between the two; and
  • verify the existence and amounts of new income or resources if these additional assets bring the individual within proximity to eligibility limits.

Case workers must be diligent in ensuring that individuals receiving personal attendant services (PAS) are served by Title XIX PAS whenever possible. If the financial situation of an ongoing Family Care (FC) individual has changed in a way that might make him eligible for Community Attendant Services (CAS), a referral should be made to Medicaid for the Elderly and People with Disabilities (MEPD) at the next financial reassessment

Example: An FC individual was denied CAS eligibility at the time of application because of resources that exceeded the $2,000 eligibility limit. However, the individual now reports a total of $1,200 in resources and all other CAS eligibility criteria (for example, a need for a personal care task) are met. At the financial reassessment, a referral to MEPD must be made.

 

2662.1 Financial Reassessments for Community Attendant Services (CAS)

Revision 21-3; Effective September 1, 2021

MEPD staff must redetermine financial eligibility for CAS annually.

Renewal packets are mailed 60-90 days prior to the annual renewal date. Complete and return Form H1200, Application for Assistance – Your Texas Benefits, along with any required verification documents, within 30 days. If Form H1200 and the required verification are not received by the due date, benefits will be denied.

During regular monitoring visits, remind CAS recipients of the importance of completing and returning the renewal form within the 30-day timeframe so they can continue to receive services. Ensure recipients are aware they can complete an annual renewal online through YourTexasBenefits.com  or over the phone by calling 211.

Some CAS recipients may receive Form H1200-SR, Streamlined Redetermination for Medicaid for the Elderly and People with Disabilities, instead of Form H1200. The cover letter for Form H1200-SR will advise the recipient that no action is needed if there are no changes to the reported information and the renewal form does not need to be returned.

Recipients who are receiving CAS and SNAP or TANF benefits will also receive Form H1010, Texas Works Application for Assistance - Your Texas Benefits. Remind CAS recipients that, in addition to completing Form H1200 to renew CAS benefits, Form H1010 must be completed and returned to continue to receive SNAP or TANF benefits.

If verification of ongoing functional eligibility is requested by MEPD at the annual redetermination, send a copy of the Service Authorization System Online (SASO) Service Authorization screenshot to show the recipient remains active on CAS. Use Form H1746-A, MEPD Referral Cover Sheet, to fax the information to the Document Processing Center (DPC).

Related Policy

Guidelines for Completing Form H1746-A. MEPD Referral Cover Sheet, Appendix V

 

2663 Reassessment of Functional Need

Revision 17-1; Effective March 15, 2017

Program Standard: The case worker reassesses the individual's need within 12 months of the previous assessment. The functional assessment must be completed by the last day of the 12th calendar month from the previous functional assessment.

To reassess functional need, use the policies and procedures in Section 2430, Functional Assessment, and in the instructions for Form 2060, Needs Assessment Questionnaire and Task/Hour Guide.

  • For services requiring a functional needs Form 2060 score for eligibility, the case worker must complete or update the score in Part A of Form 2060 at each annual reassessment.
  • For individuals who receive Day Activity and Health Services (DAHS) or Consumer Managed Personal Attendant Services (CMPAS) as the only service, a Form 2060 score is not required.
  • For Family Care (FC), Community Attendant Services (CAS) and Primary Home Care (PHC), the case worker must review Part B and Part C of Form 2060 at least annually during the interview with the individual.

 

2663.1 Annual Home Visit Required for Individuals Receiving PAS

Revision 17-6; Effective June 28, 2017

Program Standard: A home visit must be conducted with all individuals receiving Community Attendant Services (CAS) for all annual reassessments and 90 day monitoring contacts. A home visit must be conducted with all individuals receiving Primary Home Care (PHC) and Family Care (FC) at least once every 24 months at the same time the financial redetermination is conducted.

During the home visit, the case worker provides oversight of the individual's health and safety. The case worker must evaluate the individual's ability to cope with the activities of everyday living in the home environment and identify when changes to the service plan or the addition of other services provided by the Texas Health and Human Services Commission (HHSC) may be of benefit.

For CAS, it is recommended the case worker complete the annual functional reassessment during the last 90-day monitor for the year prior to the annual being due. If the annual functional reassessment is not completed during the last 90-day monitoring visit prior to the annual being due, then an additional home visit is required to complete the reassessment. An exception to having to make a home visit is when Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, has been completed within the last 60 days due to an interim change, the case worker may conduct the annual reassessment by telephone.

For all CCSE services, if an individual requests a change at the annual reassessment, the change must be worked within five days or by the annual reassessment due date, whichever is earlier.

For CAS, Form 2101, Authorization for Community Care Services, will continue to be sent within five business days of the home visit due to the nurse approval requirements for the program.

All annual reassessments must be recorded on Form 2314, Satisfaction and Service Monitoring, and in the Service Authorization System Online Wizards (SASOW). It must include the individual as the primary contact and the location as a home visit.

 

2663.2 Determining When a Home Visit is Necessary for Other Services

Revision 17-1; Effective March 15, 2017

For services other than Community Attendant Services, determine if the reassessment should be done in a face-to-face home visit or by telephone interview, based on the service received and the individual's circumstances. See Section 4000, Specific CCSE Services, for home visit requirements for each specific service.

Individual circumstances that may include the need for a face-to-face reassessment include but are not limited to:

  • a service other than Emergency Response Services or Home-Delivered Meals is being added to the service plan;
  • individuals with no telephone or who cannot communicate by telephone because of cognitive or physical impairments and/or lack a knowledgeable source to contact;
  • Community Care Services Eligibility (CCSE) individuals who are receiving services from Adult Protective Services (APS) or have a history of self-neglect;
  • individuals who have experienced multiple changes in a short time frame, such as major changes in health, living arrangements or caregiver arrangements, and the case worker is unable to obtain an accurate assessment that reflects all of the changes by telephone;
  • case transfers to case workers or newly hired case workers, unless the losing and gaining case workers discuss and agree on the individual's condition;
  • individuals with weak, unreliable or no caregiver support systems;
  • individuals who have a history of refusal to comply with service provisions;
  • individuals whose health and safety are at risk; or
  • individuals who choose to live in a home with dilapidated, unsanitary or hazardous living conditions.

Case worker circumstances may warrant that a home visit be made, such as case worker trainees assigned to a caseload.

 

2664 Redetermination of Unmet Need

Revision 17-1; Effective March 15, 2017

The unmet need policy applies to ongoing cases as well as to applications. At each reassessment, the case worker must evaluate whether the Community Care Services Eligibility (CCSE) services already being purchased are meeting needs that would go unmet if no services were purchased. During the annual functional assessment or for each request for a change in service plan or hours, review each task on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide.

In the Service Arrangement column, determine if needs are being met through other sources or if the individual continues to have a need for the task to be purchased. If there are no tasks to be purchased, the individual no longer has an unmet need and is no longer eligible. If unmet need exists, continue with the development of an appropriate service plan.

In situations in which the individual's caregiver also serves as the paid attendant, carefully review the tasks marked "C" on the Service Arrangement Column on the previous Form 2060. These are the tasks that the caregiver agreed to perform voluntarily at the last assessment. These tasks may not be purchased. If the caregiver states that he/she is no longer able or no longer willing to provide the tasks, then advise the caregiver that the provider will be notified to hire a new paid attendant for those tasks. Document any changes in caregivers or caregiver tasks on Form 2060 and Form 2059-W, Summary of Individual's Need for Service Worksheet. The information on Form 2059-W is entered in the Service Authorization System Online Wizards (SASOW) for Form 2059, Summary of Client's Need for Service.

In reassessment decisions, apply policy about duplicate services.

 

2670 Notifications at Reassessment

Revision 18-2; Effective November 19, 2018

40 Texas Administrative Code §48.3902 – To continue receiving services, the client must meet the CCSE eligibility requirements at the time of recertification of financial eligibility and reassessment of needs.

Program Standard: Notify the individual in writing, using Form 2065-A, Notification of Community Care Services, of changes in the individual's service plan, to include: addition of service(s), increase in hours, decrease in copayment, or loss of priority status based on the individual's request.

Form 2065-A must be sent within two workdays of the decision if the change involves:

  • denial of priority status if the applicant requests it;
  • an increase in units;
  • a decrease in the copayment; or
  • adding a new service.

For Community Attendant Services (CAS) case actions initiated by the Medicaid for the Elderly and People with Disabilities (MEPD) specialist, the Community Care Services Eligibility (CCSE) case worker is only required to check the notice forwarded by MEPD for accuracy and file it in the case record. The case worker's only liability for any MEPD-issued Form 2065-A is to report the error to the MEPD specialist via Form 2067, Case Information.

Program Standard: Notify the individual in writing of any reduction, termination in services, loss of priority status or increase in copayment at least 12 days before the effective date of the decision.

If an individual loses eligibility, Form 2065-A must be sent with 12 days advance notice. Exception: Advance notice is not required if the individual loses Medicaid eligibility such as Supplemental Security Income (SSI) or Temporary Assistance for Needy Families (TANF).

Program Standard: Notify the applicant/individual or his authorized representative of his rights and responsibilities and of HHSC service limitations.

The case worker gives Form 2307, Rights and Responsibilities, to the Adult Foster Care (AFC) individual/responsible person before AFC is authorized or reauthorized. The form is given to the CCSE individual/responsible person at the initial face-to-face visit. (For individuals receiving only Day Activity and Health Services (DAHS) or Home-Delivered Meals (HDM), the initial Form 2307 may be reviewed over the telephone.)

The case worker also gives Attachment 2307-A, Family Care, Community Attendant Services and Primary Home Care Rights and Responsibilities, when the applicant/individual requests attendant care and when the individual moves into a new home. At least annually, the case worker discusses all parts of Form 2307 with the individual/responsible person to ensure that he understands the form's content.

 

2680 Recertification

Revision 21-4; Effective December 1, 2021

When the reassessment is complete, send the following forms to the provider:

  • Form 2101, Authorization for Community Care Services, for all Day Activity and Health Services, Primary Home Care, Home-Delivered Meals, Family Care and Residential Care cases when there is a change in the service plan.
  • Form 2101, for all Community Attendant Services (CAS) cases, even if there is not a change in the service plan.
  • Form 2065-A, Notification of Community Care Services, for all cases when there is a change in the service plan. It is not necessary to send notification if the only change is a transfer from one provider to another.

For Adult Foster Care (AFC), send the following:

  • Form 2065-A, for all cases when there is a change in the service plan. It is not necessary to send notification if the only change is a transfer from one provider to another.
  • Form 2101, for all cases even if there is not a change.
  • Form 2327, Individual/Member and Provider Agreement, update as needed.
  • Form 2330, Assessment and Service Plan Approval for Adult Foster Care, even if there is not a change.
  • Attachment 2307-F, AFC Rights and Responsibilities, only if the recipient has moved to another home.

Related Policy

Content of Referral Packets, Appendix XIII
Effective Dates, 2811