2710 Monitoring Visits and Contacts

Revision 24-5; Effective Nov. 1, 2024

Program Standard: The caseworker must monitor the person's situation, the service(s) the person receives, and the adequacy of the service plan per the requirements of the specific service they receive.

Monitoring the service plan includes:

  • ensuring the person is authorized for the correct Community Care Services Eligibility service or program;
  • checking for the appropriate priority level; and
  • ensuring that the authorized hours or units of service meet the person's needs.

2710.1 Monitoring Initiation of Services

Revision 24-3; Effective July 1, 2024

In most situations, the three-day and 30-day initiation of service monitoring visits are not required for Community Care Services Eligibility (CCSE) cases. Phone or face-to-face monitoring visits to ensure service initiation are required for two groups of people:

  • those with priority status, both three-day and 30-day; and
  • those using the Consumer Directed Services (CDS) option for service delivery, for 30-day only.

Review Section 6332.3, Monitoring CDS Service Initiation.

For these two groups, the caseworker must:

  • contact the provider if they determine that services have not been initiated;
  • determine the reason for the delay;
  • determine when services will begin;
  • monitor the progress of service initiation; and
  • complete a service satisfaction monitoring contact within 30 days of the first monitoring contact.

Caseworkers should be aware of service initiation issues and complete optional three-day or 30-day contacts if it is deemed appropriate based on the:

  • person's medical condition to ensure their health and safety;
  • dependability of the person's family or friends resource system;
  • impact of environmental circumstances such as unsafe or unsanitary conditions that could become a barrier to service delivery; or
  • provider's ability to deliver services within the specified timelines.

Although not required, caseworkers should verify service initiation by:

  • contacting the person by phone or home visit;
  • contacting the provider contracted to deliver services;
  • reviewing notifications of service initiations from providers, including Form 2067, Case Information, or Form 2101, Authorization for Community Care Services;
  • considering other reliable verbal or written information received that verifies service initiation; or
  • providing the person with notice to contact the caseworker if services are not initiated within a designated time frame.

2710.2 Monitoring Ongoing Services

Revision 24-5; Effective Nov. 1, 2024

The minimum requirements for recipient contacts are:

  • For all recipients, except those receiving Community Attendant Services (CAS), monitor services every six months. Contact the recipient:
    • by the last day of the sixth month from the first assessment date for the initial six-month monitor; and
    • by the last day of the sixth month from the previous monitoring contact for ongoing six-month monitors.
  • For a priority recipient other than CAS make a face-to-face visit within six months of the last monitoring contact date. Example: If the previous monitoring contact was made on March 15, the next contact is due on or before Sept.14.

    Note:  Other possible circumstances may require a home visit.
     
  • For CAS recipients, the required 90-day monitoring visit must be completed with a face-to-face home visit. The 90-day monitoring visit meets the requirement of the six-month monitor.
  • For Adult Foster Care recipients, after the first three monthly monitoring contacts, regular six-month monitors must be completed. The first six-month contact is required three months after the 90-day contact.

More contacts or home visits are required if recipient circumstances warrant. Some recipients may need more monitoring, or problems may arise that require more contact. Recipients with weak or informal support systems may need to be seen more frequently. Home visits may be necessary to ensure the recipient’s safety and well-being are not compromised.

Develop a monitoring plan that considers:

  • the recipient’s functional needs;
  • the capabilities of family or friends’ resource and support systems; and
  • the impact of the recipient’s environmental circumstances.

If a home visit is required, inform recipients in advance by phone or in writing. Use Form 2068, Application, Redetermination, or Monitoring for Community Care Services, unless there is an indication of abuse, neglect or fraud.

Related Policy

Determining When a Home Visit is Necessary for Other Services, 2663.2
Monitoring Community Attendant Services People, 2711
Adult Foster Care, 4100

2710.3 Service Plan Changes at the Monitoring Contact

Revision 24-5; Effective Nov.1, 2024

Reduce hours or terminate services at annual reassessment or any other time the person:

  • requests a reduction or termination;
  • gains a resource resulting in fewer unmet needs and the need to reduce service hours; or
  • is performing all or some activities of daily living due to long-term improvement in functional condition.

The caseworker uses their judgment to determine if the person's long-term improvement is expected to last through the current authorization period or beyond before reducing or terminating services. Review Section 2721.6, Long-term Versus Short-term Changes in the Person's Condition, for more details to make that determination.

The person and provider may agree to change the number of personal attendant service (PAS) hours provided based on the person's needs without prior approval from the caseworker. The amount of service provided should be enough to meet the person's needs depending on the loss or gain in the person's functional ability to perform activities of daily living.

Caseworker approval or denial is required for all requests to increase PAS service hours previously authorized or to add or delete priority status.

2710.4 Monitoring Documentation Requirements

Revision 24-5; Effective Nov.1, 2024

The primary purpose of each monitoring contact, whether a home visit or a phone call, is to determine the adequacy of the current service plan and actual service delivery.

Form 2314, Satisfaction and Service Monitoring, must be used for all required monitoring contacts, including three-day, 30-day, 60-day, 90-day, six-month and annual. Note: All other contacts must be documented. During each monitoring visit, assess the quality of services and if the services continue to meet the needs of the recipient by determining that:

  • services are delivered per the service plan and as agreed to by the recipient and the provider agency;
  • the attendant comes and leaves as negotiated by the recipient, attendant, and provider agency;
  • the recipient is satisfied with each of the services being delivered; or
  • there is a need to change the priority status, increase hours, or change other services.

Ask enough questions during each contact to ensure the recipient’s current responses, together with the written case record, address each of the criteria listed above. Review Appendix XVI, Monitoring Questions, for examples of specific questions that may be appropriate.

At every contact, document each of the following:

  • Eligibility — Does the recipient continue to meet all eligibility requirements for the authorized services?
  • Condition or Status — Has there been any change in the recipient's condition or situation that affects service delivery or adequacy of the service plan, such as priority status or the need for more hours or other services?
  • Quality of Services — Have services been delivered per the service plan? Does the attendant perform the required tasks and arrive and leave as scheduled? Is the recipient satisfied with the services that have been delivered?
  • Adequacy of Service Plan — Does the service plan need to be changed?

The recipient or the provider agency may request changes in services.  Document all requests for changes on Form 2067, Case Information, and include the date the request was received. If the recipient requests a change during the monitoring contact, document the request, the request date, and the action to be taken on Form 2314.

Enter all required monitoring contacts in the Service Authorization System Online (SASO) Monitoring Wizard. A copy of the SASO automated Form 2314 must be filed in the case record.

Related Policy

Service Authorization System Online (SASO) Wizards and Use Requirements, Section 7300

2710.5 Actions Required After Monitoring

Revision 24-5; Effective Nov. 1, 2024

Caseworkers report and discuss with the provider any problems or deficiencies in service provision and strive to resolve them. Review Section 2736.1, Reporting Service Delivery Issues, for detailed instructions for handling service delivery issues.

2711 Monitoring Community Attendant Services People

Revision 24-5; Effective Nov. 1, 2024

People receiving Community Attendant Services (CAS) are eligible for personal attendant services (PAS) under the provisions of Section 1929(b) of the Social Security Act. The act requires the caseworker to monitor the home and community care by visiting each person’s home or community setting where care is being provided at least once every 90 days.

An HHSC caseworker must meet this requirement by conducting a face-to-face visit with the person receiving CAS in the person’s home or community setting where CAS services are being provided. This face-to-face visit must occur at least once every 90 days. The 90-day visit will be for monitoring the person’s satisfaction with services.

The Texas Health and Human Services Commission (HHSC) must make every reasonable attempt to complete the CAS monitoring, as the Social Security Act requires. To meet the reasonable attempt requirement, caseworkers must adhere to the following guidelines:

  • The 90-day monitoring must be completed at least every 90 days with the person or primary caregiver present in the location where services are delivered.
  • All attempts to contact the person must be documented to support the efforts to meet the federal requirement. A 90-day monitoring contact may not be made with an employee of the provider serving the person.
  • If the 90-day monitoring visit becomes delinquent, it must still be completed at the earliest possible opportunity. The caseworker must document all attempts to contact the person and the reason for the delay until the monitoring is completed.
  • In cases where the person is in a nursing facility, hospital, or out of the service area, the 90-day monitor must be conducted within 14 calendar days of learning the person has returned to the home or community setting where services are provided. The caseworker must document the dates and reasons for the person's inaccessibility.

Federal law specifically requires home visits every 90 days, not every three months. This 90-day deadline will usually be one or two days short of three calendar months. Example: If a CAS case is monitored on March 15, the next monitoring visit must be on or before June 13, the 90th day after March 15. Review Appendix XVIII, Time Calculation.

For CAS cases, HHSC staff sets the initial 90-day home visit schedule from the date within 90 days of the initial start of care (SOC), as determined by the regional nurse and documented on Form 2101, Authorization for Community Care Services, in the Service Authorization System Online (SASO). The caseworker is not required to conduct a 90-day monitor home visit before the SOC date determined by the regional nurse. Once the initial SOC has been determined, HHSC staff sets subsequent 90-day monitors using the Deadline Calculation Chart within Appendix XVIII to calculate when the next 90-day monitoring visit is due. It is recommended that caseworkers conduct the annual reassessment simultaneously with the 90-day monitor due before the first annual reassessment to align future 90-day monitors due at the annual reassessment.

All 90-day monitors must be recorded on Form 2314, Satisfaction and Service Monitoring, in the Service Authorization System Online (SASO) Monitoring Wizard. Review Section 7300, Service Authorization System (SAS) Wizards and Use Requirements, and Section 8170, Service Authorization System Help File, for help completing the SASO monitoring visit.

Inform Medicaid for the Elderly and People with Disabilities (MEPD) of any changes that may affect the eligibility of a CAS person.

2712 Six-Month Monitoring Contacts

Revision 24-5; Effective Nov. 1, 2024

When a six-month monitoring contact is required but a home visit is not, the contact may be completed by phone. If the person does not have a phone or cannot communicate by phone, and a caregiver or relative can tell the caseworker about the person's condition, service needs and the adequacy of service delivery, the contact may be with a caregiver or responsible relative. If contact cannot be made by phone with the person, caregiver or responsible relative, a face-to-face visit is required. All attempts to contact the person must be documented.

Before a face-to-face or phone contact is made with someone other than the person, make at least two attempted contacts with the person. Document all attempts to contact the person.

For a priority status person, the six month monitoring contact must be a face-to-face visit within six months of the previous contact. Example: If the previous monitoring contact was made on March 15, the next contact is due on or before Sept. 14.

During each six-month monitoring contact, ask about the:

  • current condition and situation of the person; and
  • appropriate delivery of services.

Determine if any changes are needed in the service plan. The caseworker may have to make a face-to-face contact if the:

  • phone contact shows a significant change and the caseworker cannot adequately assess the situation without a home visit Review Section 2721, Functional Changes;
  • contact shows a need to add a service or increase hours Review Section 2663.2, Determining When a Home Visit is Necessary for Other Services; or
  • person shows dissatisfaction with services and the caseworker cannot adequately assess the situation without a home visit.

A face-to-face contact is not required if the person requests a decrease in hours unless eligibility could be affected.

2720 Interim Changes

Revision 17-1; Effective March 15, 2017

 

2721 Service Plan Changes

Revision 24-5; Effective Nov. 1, 2024

Changes to the service plan may be necessitated by changes in the person’s functional abilities or personal circumstances, including:

  • hospitalizations;
  • severe acute illnesses or accidents, or recoveries from significant illnesses or accidents;
  • loss of or changes in caregivers; and
  • moves or changes in living arrangements.

2721.1 Person's Responsibility to Report Changes

Revision 24-5 Effective Nov. 1, 2024

Discuss with the person the importance of reporting changes. Explain the consequences of failing to do so. If the person receives Primary Home Care (PHC), Community Attendant Services (CAS), Family Care (FC), or Home-Delivered Meals (HDM), explain the need to notify the provider if the person will not:

  • be home when services are scheduled; or
  • need services when scheduled, important for people with priority status receiving personal attendant services.

2721.2 Provider Responsibility to Report Changes

Revision 24-5; Effective Nov. 1, 2024

Attendants report to their supervisors any changes in the person's status or environment that threaten the person's health or safety, or that may affect their service plan. The provider’s supervisor reports these changes to the caseworker. Examples of these changes include hospitalizations, episodes of illness, changes in functional abilities, bruises, mental instability that endangers the person or others, onset of incontinence, unusual complaints of pain, unusual behaviors, or unusual changes in food intake.

The attendant also reports changes that may affect social resource systems, family relationships and assistance programs.  Examples include changes or problems in housing, household make-up, loss or change in caregiver arrangements, or loss of benefits. If necessary, refer the person to Adult Protective Services.

If a provider fails to report changes that affect a person's service plan, the problem must be discussed with the provider staff. If the problem continues, document the instances, and discuss them with the Community Care Services Eligibility (CCSE) supervisor, who notifies the contract manager and program manager.

2721.3 Determining if a Home Visit is Necessary

Revision 24-5; Effective Nov. 1, 2024

The caseworker will use their judgment to decide if they have enough information to respond to the reported change without visiting the person. If in doubt, a home visit should be made. Consider the following when making that determination:

  • Is the caseworker already very familiar with the person's situation?
  • Does the information available about the change and its impact seem clear and appear reliable?
  • Is the reported change relatively simple or more complex? Examples: Several changes at once or sudden and severe deterioration.
  • Is there disagreement between what others say the person now needs and what the person is saying they need?

Make a home visit and complete a functional reassessment if the person needs or requests a new service, and their current Form 2060, Needs Assessment Questionnaire and Task/Hour Guide score is below the minimum score for that service.

Reduce hours or terminate services at annual reassessment or any time before the annual review when the person:

  • requests a reduction or termination;
  • gains a resource resulting in fewer unmet needs and the need to reduce service hours; or
  • performs all or some activities of daily living due to long-term improvement in functional condition resulting in the need to reduce or terminate services.
     

2721.4 Revising the Service Plan

Revision 24-5; Effective Nov. 1, 2024

Program Standard: The caseworker must revise the service plan within 14 calendar days of learning that the person's status or condition changed, or must document why no changes to the service plan are needed. If the caseworker becomes aware of the need for a service plan change because of conducting an annual reassessment, the change must be completed as part of that reassessment.

Contact the person and determine if a new assessment, a revised service plan, or a revised monitoring plan is needed based on the person's new condition or situation. Assess the needs of the person and develop or revise the person's service plan, including:

  • Form 2060, Needs Assessment Questionnaire and Task/Hour Guide;
  • personal assistance services tasks;
  • priority level; and
  • number of hours or units of service the person is authorized to receive per week.

2721.5 Long-term Versus Short-term Changes in the Person's Condition

Revision 24-5; Effective Nov. 1, 2024

The caseworker uses their judgment to determine if the change in the person's condition is expected to last through the current authorization period or beyond before reducing or terminating services. Do not reduce or terminate services if it is determined the person is experiencing temporary improvement in functional condition.

If it is determined the person's condition has temporarily improved because the person is performing tasks previously done by the attendant, the person and provider may agree to fewer hours per week. Send the provider Form 2067, Case Information, to inform the provider that fewer service hours may be provided if the person agrees to the reduction. In this situation, the caseworker would not update the Service Authorization System Online (SASO) record or send Form 2065-A, Notification of Community Care Services, to the person for a reduction of hours.

If a change in the person's condition impedes their functional ability to perform activities of daily living, it may be necessary to add additional hours or tasks to the service plan. Caseworker approval or denial is required for all requests to increase personal attendant services hours previously authorized or to add or delete priority status. The amount of service provided must be enough to meet the person's needs.

2721.6 Authorizing and Documenting Changes

Revision 24-5; Effective Nov. 1, 2024

Document all requests for changes in services, including the date of the request, whether received from the person or the provider.

Make all necessary changes in the service arrangement column on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide. To authorize changes in priority level or hours, update and submit Form 2101, Authorization for Community Care Services. Send Form 2065-A, Notification of Community Care Services, to the person if the:

  • Primary Home Care, Community Attendant Services, or Family Care hours increase or decrease;
  • person gains or loses priority status;
  • number of home-delivered meals per week changes, or
  • authorized units of Day Activity and Health Services change.

Document the outcome of the change request. If it is determined that no revision is needed in the service plan, document the decision and the reason. Use Form 2067, if the provider or regional nurse requested the change.

2722 Person Moves and Case Transfers

Revision 24-5; Effective Nov. 1, 2024

At times, a person's move requires transferring the person's case to a new caseworker within the same region or a different region.

When a person moves to an area served by a different caseworker within the same region or outside the region, the case remains open, and the existing service plan stays in effect until a new plan is implemented. Make every effort to minimize gaps in coverage for the person. Although the old plan remains in effect until amended, actual services may have to be temporarily suspended. Example: The new area or region does not have space in a Residential Care (RC) or Day Activity and Health Services (DAHS) facility. The caseworker who is notified of the move should initiate the action for the transfer.

2722.1 Procedures If the Losing Caseworker Initiates Action

Revision 24-5; Effective Nov. 1, 2024

If the current, losing, caseworker is contacted by the person or the person’s representatives, and the person has not already moved, that caseworker must:

  • contact the office in the new location and get the name, address, and phone number of the gaining caseworker to give to the person;
  • contact the gaining caseworker by phone and discuss the case;
  • provide the gaining caseworker with the individual number so the caseworker can access the Service Authorization System Services (SASO) for current  information;
  • have the gaining caseworker fax a provider choice list if the current provider does not provide services in the new area.
    • if the same provider will be serving the person in the new location, the losing caseworker keeps Form 2101, Authorization for Community Care Services, open and the gaining caseworker makes any needed changes.
    • if moving to another region, the provider number may be different even if the person is staying with the same agency;
  • provide the person with the caseworker and provider information and if the person has selected a new provider, relay that information to the gaining caseworker with a projected date of transfer;
  • forward the case record to the gaining caseworker within three business days of confirming the move;
  • send Form H1746-A, MEPD Referral Cover Sheet, if applicable, advising of the new address so that the MEPD case can also be updated; and
  • advise staff for any other services the person is receiving that the person has moved. 

2722.2 Procedures If the Gaining Caseworker Initiates Action

Revision 24-5; Effective Nov. 1, 2024

It is the gaining caseworker's responsibility to:

  • update Form 2101, Authorization for Community Care Services, by entering in the comments section that this is a transfer case and including the negotiated start date and the losing provider's end date;
  • mail Form 2101, Form 2059, Summary of Client's Need for Service, and the Provider Referral Supplement to the new provider agency;
  • advise the losing caseworker that Form 2101 has been updated when then must print a copy of Form 2101 and send it to the losing provider;
  • update any current Community Care Interest List entries for the person for the new area;
  • send Form H1746-A, MEPD Referral Cover Sheet, for all Community Attendant Services (CAS) people to Medicaid for the Elderly and People with Disabilities (MEPD);
    • advise that the person has moved to the service area and has a continued need for service;
    • provide the old and new addresses;
  • contact the person within 14 calendar days to assess the person's new living arrangements and need for service plan changes;
  • schedule a home visit If needed; and
  • review Section 2663.2, Determining When a Home Visit is Necessary for Other Services, to determine if a home visit is necessary.

2722.3 Additional Procedures

Revision 17-1; Effective March 15, 2017

The regional nurse does not need to give prior approval unless a reassessment is being conducted at the same time the transfer is being done, and then a copy of Form 2101, Authorization for Community Care Services, needs to be forwarded to the regional nurse with the transfer agency information.

The provider does not have to obtain new physician's orders for prior approval from the regional nurse for a transferring case.

2723 Freedom of Choice

Revision 24-5; Effective Nov. 1, 2024

In areas where there is more than one provider for a specific service, allow the person the freedom to choose and change providers without restriction.

When a person requests to change providers, the caseworker must first determine the person's reason for dissatisfaction and whether the person's satisfaction can be met without the provider change. The caseworker completes the following steps within fourteen days of the person's request:

  1. Ask the person or their representative to select a new provider and document the choice.
  2. Coordinate with both providers the date the current provider will stop providing services and the date the new provider will begin services.
  3. Update the information on Form 2059, Summary of Client's Need for Service.
  4. Update Form 2101, Authorization for Community Care Services, by entering:
    • the nine-digit vendor provider number; and
    • a statement in the comments section documenting the coordination with both providers and the effective date of the change.
  5. Send the new provider Form 2110, Form 2059 and Form 2101.
  6. For non-Community Attendant Services (CAS) cases, send the current losing provider a copy of Form 2101 that reflects the effective date of the transfer.
  7. On CAS cases where the change is being made in conjunction with an annual reassessment, the regional nurse will:
    • update Form 2101 upon receipt; and
    • send the updated form that shows the effective date of the transfer to the new provider.

The caseworker will send the current, losing provider a copy of the updated form that reflects the effective date of the transfer.

In situations that the person has been suspended due to health and safety reasons and services will continue with a new provider, the HHSC caseworker must determine how much information to share with the new provider about the previous actions. Review Section 2840.1, Sharing Information with New Providers Regarding Health and Safety Issues.

2724 Medicaid Coverage for People Denied SSI

Revision 24-5; Effective Nov.1, 2024

In most instances:

  • receipt of Supplemental Security Income (SSI) entitles a person to Medicaid; and
  • loss of SSI eligibility also means loss of Medicaid benefits.

However, there are several exceptions to this, particularly when someone loses SSI eligibility because of income from Social Security benefits. If a CCSE person receives both SSI and Social Security benefits and the SSI is denied because of income associated with Social Security, encourage the person to apply to Medicaid for the Elderly and People with Disabilities (MEPD)  for an eligibility determination. Send a H1746-A, MEPD Referral Cover Sheet to MEPD if the person is interested.

2725 Certificates of Insurance Coverage

Revision 24-5; Effective Nov. 1, 2024

Public Law 104-191, the Health Insurance Portability and Accountability Act of 1996 (HIPAA), requires that health insurers, including Medicaid, furnish certificates of creditable coverage whenever a person ceases coverage under a plan or policy. The certificate provides evidence that the person had prior creditable health insurance coverage that counts toward reducing or eliminating pre-existing condition exclusions under any subsequent health insurance coverage the person may get.

This legislation will affect people who are Medicaid recipients. Information about certificates of coverage is provided to CCSE applicants and people on Page 2 of Form 2065-A, Notification of Community Care Services.

Texas Medicaid & Healthcare Partnership (TMHP) is the contractor that produces these certificates for denied Medicaid people. If a person has questions about the certificate or needs a replacement certificate, they should write or call TMHP.

2730 Special Procedures for Helping Individuals Enter or Leave a Nursing Facility, Institution, or Hospice

Revision 17-1; Effective March 15, 2017

 

2731 People Entering a Nursing Facility

Revision 24-5; Effective Nov. 1, 2024

Some people living in their own homes may need counseling about the available options for receiving long-term care, including nursing facility placement. Caregivers of people with heavy care needs may experience severe stress or be unable to continue their duty for weeks and months without reprieve. People may be at risk if they remain in their current environments. Assess these situations from the standpoints of both the person's safety and the caregiver's ability to withstand the stress of constant care. Offer them the opportunity to consider nursing facility care.

If a person wants to enter a nursing facility, help them make their plans. If the person is not a Medicaid recipient, refer them to Medicaid for the Elderly and People with Disabilities (MEPD) staff to start the financial application process as soon as possible.

If a person lacks family or a responsible person to help them with all the final activities involved in moving into a nursing facility, help them by involving their friends and other volunteers.

Nursing Facility Care for People Under 22

State Law Chapter 242, Health and Safety Code requires that the Community Resource Coordination Group (CRCG) be notified by the third day after the date a Community Care Services Eligibility child under 22 with a developmental disability is initially placed in an institution.

Call the CRCG State Office at 512-206-4564 to get the name and phone number of the CRCG contact person. A CRCG list is also available online (PDF).

If notice is received of an initial placement of a child in an institution, contact the person making the placement to ensure that family members of the family are aware of:

  • service and support that could provide an alternative to placement of the child in the institution; and
  • available placement options.

2732 Closing Service Authorizations for Individuals Entering or Leaving a Nursing Facility

Revision 17-1; Effective March 15, 2017

 

2732.1 People Entering a Nursing Facility

Revision 24-5; Effective Nov. 1, 2024

A batch process closes the service authorization records for Community Care people who have entered a nursing facility. When Form 3618, Resident Transaction Notice, is submitted by the nursing facility, all Service Authorization System Online (SASO) authorization records, except Service Code 20-Emergency Response Services, are closed by an automated batch process that occurs five times a week.

The batch process uses the date in Item 11, date of the above transaction, on Form 3618 as the end date of the service authorization.

Regional Claims Management System (CMS) coordinators must access the reports and notify caseworkers when they have people whose service authorization records are closed by the batch process. Caseworkers must monitor these cases for 30 calendar days until it is determined if the person's nursing facility stay will be long term. If the person will be remaining in the facility, the caseworker closes the remaining Service Code 20 record, if applicable.

2732.2 People Leaving a Nursing Facility

Revision 24-5; Effective Nov. 1, 2024

For people being discharged from a nursing facility who are beginning to receive Community Care services, Provider Claims Services has established a hotline number to call to close the nursing facility authorization. The hotline number is 512-438-2200. Select Option 1.

The caseworker should call the hotline directly to request the nursing facility record in the Service Authorization System Online (SASO) be closed so Community Care services can be authorized. The caseworker must confirm the person has been discharged from the facility and Community Care services are negotiated to begin on or after the date of discharge.

When calling the hotline, the caseworker must identify themself as a Texas Health and Human Services Commission (HHSC) employee and report that the person has discharged from the nursing facility and provide the discharge date. The Provider Claims Services representative will close all Group 1 Service Authorizations and Enrollment in SASO, including the Service Code 60. The caseworker documents the contact. 

2732.3 People Denied a Determination of Medical Necessity

Revision 24-5; Effective Nov. 1, 2024

When a Medicaid nursing facility resident is denied a determination of medical necessity, Texas Medicaid & Healthcare Partnership (TMHP) sends a denial letter to the person and the person's physician. The facility and Medicaid for the Elderly and People with Disabilities (MEPD) are notified by TMHP's weekly status report.

If the person requests CCSE services, respond to this request by following the usual intake procedures, including interviewing, and assessing their needs. If the person is determined eligible to receive CCSE services but prefers to receive services outside the intake unit's geographical area, the intake unit staff refers the case to the appropriate caseworker or region. When CCSE staff receive an out-of-town referral or inquiry, they help with alternate placement activities.

2732.4 Promoting Independence Initiative

Revision 24-5; Effective Nov. 1, 2024

Promoting Independence (PI) Initiative, enacted by House Bill 1867 of the 79th Session of the Texas Legislature, helps ensure a system of services and supports that foster independence and productivity, and provides meaningful opportunities for people that are older and people with disabilities to live in their home communities.

Money Follows the Person (MFP) is available for people requiring waiver services. It allows Medicaid funds that are being used to pay for the person's care in a nursing facility to be transferred to pay for Medicaid waiver services in the community. People identified as using MFP-funded services do not use interest list allocations.

MFP does not apply to Community Care Services Eligibility programs.

Review the appropriate program handbook for the desired waiver program for more information.

2733 Individuals Receiving Services through Local Authorities

Revision 17-1; Effective March 15, 2017

Local Authorities (LAs) specialize in working with persons who have intellectual developmental disabilities (IDDs), intellectual disabilities (IDs) or persons with mental illness, especially those who are in crisis situations. Close coordination with LA is vital to ensure the safety and well-being of the individual and others. Contact the local LA agency to determine what procedures to follow to obtain permission from the individual to discuss his case with LA staff.

The liaison case workers at the LA community center are responsible for helping individuals with IDD/ID with the process of admission to or discharge from state supported living centers or intermediate care facilities for individuals with an intellectual disability or related condition (ICF/IID). Refer to the appropriate liaison worker any persons requesting or requiring entry into these facilities. Liaison case workers also have primary case management responsibility for individuals with IDD/ID who return to the community from state supported living centers. Contact liaison workers for specific information about their responsibilities and about the availability of LA resources for individuals with IDD/ID.

Persons discharged from state hospitals are referred to the appropriate LA community center or outreach program for follow-up. LA case management services are available to them if they meet eligibility and priority criteria. Contact the liaison worker for specific eligibility information. These individuals may also apply personally for CCSE services.

If there is no LA case worker assigned to the individual's case, contact the local LA agency to discuss the individual's condition. Refer the individual to them for services, assistance and/or case management, if appropriate. Include the LA case worker in the development of the individual's CCSE service plan and clearly define the case worker's roles and responsibilities in managing the case. Encourage the LA case worker to offer support counseling and training to the:

  • individual;
  • the individual's caregiver; and
  • provider of services.

Keep the LA case worker informed of changes in:

  • the individual's environment (such as hospitalizations, residence, household composition);
  • the individual's physical/mental condition;
  • medications or lack of medication; and
  • the service plan.

Document in the case record contacts with LA staff, including any agreements reached.

Refer to Appendix XV, Services Available from Other State Agencies, for a list of the services that may be available through the LA agency.

Note: Refer to Section 1140, Disclosure of Information, regarding disclosure of information and national standards created under the Health Insurance Portability and Accountability Act to protect the confidentiality of individually identifiable health information.

2734 Texas Department of Corrections (TDC) People Leaving TDC

Revision 24-5; Effective Nov. 1, 2024

Texas Department of Corrections (TDC) staff are responsible for discharge planning for people who are older or people with disabilities being released from TDC. TDC tries to make a referral at least 30 calendar days before the inmate will be released from prison. TDC is represented in the community by the Board of Pardons and Parole (BPP). BPP supervises the person in the community and provides or arranges for other services they may need. Follow the usual case management procedures to certify the person eligible for services, to refer their case for service, and to monitor or evaluate any services authorized.

2735 People Who Need Hospice Services

Revision 24-5; Effective Nov. 1, 2024

Medicare and Medicaid hospice services are available to terminally ill Medicare and Medicaid eligibles who file an election statement with a particular hospice. Hospice applicants must be certified as terminally ill, with six months or less to live, by a physician. For dually eligible people who elect hospice care, coverage is concurrent with the Medicare and Medicaid programs. Hospice care is also available on a private-pay basis.

Hospice staff contact the caseworker by phone about the start and cancellation dates for hospice care. Hospice staff no longer send a copy of Form 3071, Individual Election/Cancellation/Update, to HHSC staff. People may elect or cancel hospice care at any time.

People electing hospice may be eligible for services through HHSC if there is no duplication in the services delivered. A Medicaid recipient, 21 and older, who elects Medicaid hospice waives their rights to other programs with Medicaid services related to the treatment of a terminal illness. The Medicaid recipient does not waive their rights to services offered by HHSC that are unrelated to the treatment of the terminal illness. People under 21 years of age who elect hospice do not waive rights to Medicaid services related or unrelated to the terminal illness.

HHSC caseworkers must follow up with the person receiving services to determine what hospice will provide and adjust the person’s service plan to ensure no duplication of services. Caseworkers must respond to a notification of hospice election within the time frame of a change request.

The unmet need policy in Section 2433, Determining Unmet Need in the Service Arrangement Column, does apply to hospice people. Coordinate any CCSE service plan with the hospice provider to prevent duplication and assure adequate services to the person. If the hospice provider adequately meets a person's need for help with a particular task, do not authorize purchased services for that task.

If the hospice provider does not meet the need for help, or if the need is only partly met, authorize services on the same basis as those used for any other person.

Caseworkers may receive a request to initiate a CCSE service for a person already receiving that service from a hospice. In this case, it must be determined if the hospice will continue to provide the needed care. Authorize the CCSE service if the hospice service ends on a certain date or if the hospice provider will provide the service only until the CCSE service can begin. Coordinate service initiation and ending dates with the hospice provider to prevent a break in services. When a CCSE person enters a nursing home under hospice, terminate CCSE services effective the date the person entered the facility. If the person receives hospice care at home, making reduction or termination of CCSE services necessary, give the person the usual 12-day advance notice before the effective date of the reduction or termination.

If a person with Medicaid for the Elderly and People with Disabilities (MEPD) eligibility determination (Community Attendant Medicaid Hospice Program Services) enters a nursing facility under Medicaid hospice, the caseworker notifies the MEPD of the Hospice nursing facility entry and closure of the HHSC case by sending Form H1746-A, MEPD Referral Cover Sheet.

In related situations, hospice services should be considered as a resource available to CCSE applicants and recipients. Monitor CCSE people on an ongoing basis to determine if they need or are receiving hospice services.

Note: Refer to Section 1140, Disclosure of Information, about disclosure of information and national standards created under the Health Insurance Portability and Accountability Act to protect the confidentiality of individually identifiable health information.

2736 Complaints, Grievances or Suggestions

Revision 24-5; Effective Nov. 1, 2024

The applicant or person has the right to lodge a complaint, voice a grievance, or recommend changes in policy or service without restraint, interference, coercion, discrimination or reprisal. Staff must:

  • acknowledge the complaint, grievance, or recommendation within 14 calendar days of the date the Texas Health and Human Services Commission (HHSC) receives it; and
  • resolve it within 60 calendar days of that date.

2736.1 Reporting Service Delivery Issues

Revision 24-5; Effective Nov. 1, 2024

Provider service delivery issues may be reported to the Texas Health and Human Services (HHS) Office of the Ombudsman. These reports may be generated by:

  • the person or person's representative;
  • Texas Health and Human Services Commission (HHSC) staff, including issues discovered by the caseworker or reports received during monitoring contacts; and
  • other people, including the person's family and friends.

Service delivery issues include any dissatisfaction expressed by the person about a service delivery provider. The person may express dissatisfaction about:

  • the quality of a service provided, such as care, treatment or services received;
  • aspects of interpersonal relationships, such as rudeness; or
  • the service provider's failure to:
    • respect the person's rights;
    • follow terms of the contract or applicable rules; or
    • provide services that may or may not have had an adverse effect on the person.

This list is not all-inclusive.

Report complaints of a regulatory nature about nursing facilities, home and community support service agencies, intermediate care facilities, assisted living facilities, day activity and health services, prescribed pediatric extended care centers, and Home and Community-based Services and Texas Home Living providers to Consumer Rights and Services at 800-458-9858 or ciicomplaints@hhs.texas.gov to generate an investigation by HHSC Regulatory Services.

Within five business days of receiving a report or becoming aware of service delivery issues, the caseworker:

  • must respond to the person and the provider either by phone or face-to-face contact to discuss the issues;
  • must inform the provider of the service delivery issues and discuss resolutions;
  • convenes an interdisciplinary team (IDT) meeting if appropriate;
  • coordinates with the person and provider to implement actions required to resolve the issues;
  • must document the receipt of the report and contacts with the person and the provider in the case record;
  • must document any barriers or hindrances by either party that interfere with the resolution of the issues; or
  • attempts to resolve the issue must be documented.

If service delivery issues cannot be resolved within 10 business days of the initial receipt of a report or of becoming aware of service delivery issues, the caseworker must:

  • report the service delivery issues to the HHS Office of the Ombudsman at 877-787-8999;
  • inform the person of their right to call the HHS Office of the Ombudsman to register a complaint about the provider, including a Consumer Directed Services (CDS) agency; and
  • inform the person of their right to choose another provider.

The caseworker must make the report to the HHS Office of the Ombudsman within three business days after the 10 business day resolution period ends.

In situations where service delivery issues may compromise the person's health and safety, the caseworker must report within 24 hours of receiving the report or becoming aware of service delivery issues. The caseworker must:

  • also contact Adult Protective Services (APS) or Child Protective Services (CPS) within 24 hours if there is an immediate or imminent threat to the health and safety of the person; and
  • continue to work with the person and provider to resolve the issues within the 10 business day time frame.

The caseworker must identify the specific service the provider is delivering when calling to report a complaint.  Example: the caseworker identifies the provider as a Primary Home Care (PHC) provider when making a referral that involves PHC service delivery issues. The caseworker must provide specific information related to the service delivery issues, including actions taken to resolve the issues and why the actions did not resolve them.

2740 Fraud Detection and Documentation

Revision 17-1; Effective March 15, 2017

 

2741 Provider Fraud

Revision 24-5; Effective Nov. 1, 2024

The Texas Health and Human Services Commission (HHSC) endorses the concept that people who provide services are essentially honest and are entitled to the same protection under the law as all other people. However, when there is an indication of potential fraud, the allegations must be investigated, and the following must be established:

  • intentional misstatement or concealment by the provider created a false impression; and
  • HHSC paid the provider based on a false impression, and the payment would not have been made if the truth had been known.

Examples of provider fraud include:

  • billing for services which were not provided;
  • provision of services which are not medically necessary;
  • filing false claims;
  • continuing inappropriate billing after provider education visits;
  • billing for services provided by inappropriate persons;
  • practicing without a proper license or obtaining a license under false pretenses;
  • using improper billing practices; and
  • violating the contract or provider agreement.

Note:  This list is not all-inclusive.

2742 Responding to Allegations of Provider Fraud

Revision 17-1; Effective March 15, 2017

When an allegation of provider fraud is received, staff should follow these procedures:

  • During the first contact, staff receiving the complaint should obtain facts relating to the specific case in as much detail as possible. This includes:
    • who engaged or participated in the alleged fraudulent conduct,
    • what the suspected violation was,
    • when the conduct occurred (dates or time periods),
    • where the conduct occurred,
    • how the fraudulent action was performed, and
    • the names of witnesses and how they can be contacted.
  • Staff should try to obtain the complainant's name, address, home telephone number and telephone number where the complainant can be reached during the day. Staff should advise informants who wish to remain anonymous that the Texas Health and Human Services Commission (HHSC) needs a way to contact them during the investigation.
  • Staff must not make any agreements or commitments to anyone regarding the investigation or any possible adverse action.

2743 Individual Fraud

Revision 24-5; Effective Nov. 1, 2024

People receiving HHSC services are perceived as honest and entitled to the same protection under the law as all other people. However, when there is an indication of potential fraud, the allegations must be investigated, and the following must be established:

  • intentional misstatement or concealment by the person or authorized representative created a false impression; and
  • The Texas Health and Human Services Commission or contracted provider delivered services based on false impressions, and the services would not have been provided if the truth had been known.

Examples of individual fraud include:

  • knowingly providing false information about an applicant's financial, medical, or functional status to be determined eligible for assistance;
  • withholding or concealing information about the applicant's financial, medical or functional status, which may cause the applicant to be ineligible for services;
  • receiving services which the person knows to be medically unnecessary; or
  • knowingly receiving services from people who do not have a proper license or who obtained a license under false pretenses.

Note:  This list is not all-inclusive.

2744 Responding to Allegations of Individual Fraud

Revision 24-5; Effective Nov. 1, 2024

When potential individual fraud is discovered, staff should follow these procedures:

  1. Record all pertinent facts relating to the specific case in as much detail as possible. This includes:
    • who engaged or participated in the alleged fraudulent conduct;
    • what the suspected violation was;
    • when and where the conduct occurred;
    • how the fraudulent action was performed; and
    • the names of people who are knowledgeable about the situation and how they can be contacted.
  2. If a third party alleges fraud, staff should try to get the complainant's name, address, and phone number so the complainant can be reached during the day. Staff should advise informants who wish to remain anonymous that the Texas Health and Human Services Commission (HHSC) needs a way to contact them during the investigation.
  3. Staff must not make any agreements or commitments to anyone about the investigation or any possible adverse action.

Restitution must not be requested in cases where fraud is being pursued. Restitution is securing payment from a person when fraud is not indicated. Once restitution is requested, you cannot refer the case for fraud.

2745 Reporting Suspected Fraud in the Consumer Directed Services Option

Revision 24-5; Effective Nov. 1, 2024

The following are established procedures for reporting suspected fraud in the Consumer Directed Services (CDS) option to the Office of Inspector General (OIG). These apply when there is suspected fraud committed by the person receiving services, the CDS employer or the CDS employee. They do not apply to provider fraud.

When the HHSC caseworker suspects fraud was committed by the person receiving services, the CDS employer or the CDS employee, or is made aware of suspected fraud from an entity other than the Financial Management Services Agency (FMSA), the caseworker must report the suspected fraud to the OIG. The caseworker can submit the referral using the OIG website, or by calling 800-436-6184. The caseworker must inform the OIG the person is using the CDS option.

If the caseworker does not receive a referral number after submitting the information on the OIG website, it means the referral may not have transmitted successfully. The caseworker must call 800-436-6184 to confirm the OIG received the referral and ask for the referral tracking number. The caseworker must document the suspected fraud and referral information.

Once the caseworker submits the fraud referral to the OIG, they inform the FMSA about the suspected fraud and that a referral was made to the OIG using Form 2067, Case Information. The caseworker must also send a secure email to CDS Operations staff, at the state office containing the following information for tracking purposes:

  • name of the FMSA;
  • name of the person(s) suspected of committing fraud;
  • as much identifying information as possible, such as Social Security number, Medicaid number, date of birth, address and phone number;
  • brief summary of the fraud allegation, including dates and estimated cost because of the violation;
  • date the fraud allegation was reported to the OIG and the OIG referral tracking number;
  • program or service impacted; and
  • contact information for the HHSC caseworker who submitted the referral and the HHSC office where the caseworker is located.

When an FMSA suspects fraud was committed by the person receiving services, the CDS employer or the CDS employee, the FMSA makes a referral to the OIG. The FMSA informs HHSC CDS Operations staff at state office that the FMSA submitted a fraud referral to the OIG for tracking purposes.

The FMSA also informs the HHSC caseworker that a fraud referral was submitted to the OIG using Form 2067. The caseworker must file Form 2067 received from the FMSA in the person’s case file. No further action is needed by the caseworker about the fraud referral once the FMSA notifies HHSC the referral was made to the OIG.

2750 Fraud Referral

Revision 24-5; Effective Nov. 1, 2024

 

2751 Development of the Fraud Referral Packet

Revision 24-5; Effective Nov. 1, 2024

Consult the unit supervisor for guidance in determining the appropriateness of the referral and the information being provided. If it is decided that a referral will be submitted, complete the online reporting document, Form H4834, Individual or Recipient Provider Fraud Referral/Status Report, available at the Inspector General webpage. The online reporting system prompts the user to enter:

  • the name of the person providing information;
  • additional contact person information, if available;
  • the name of the person completing the form, if different from the person providing the information;
  • law enforcement information, if available indicate if law enforcement was notified;
  • witness information, if available;
  • the name of the person or facility being reported; and
  • detailed information about the waste, abuse or fraud concern, including:
    • provider identification including the name, provider type and specialty, business address, residence address and provider numbers;
    • identification of the alleged illegal act including specific data about potential witnesses, addresses, work and home phone numbers;
    • names, mail codes and phone numbers of all staff who can provide information;
    • identification of policy, regulation or procedural violations;
    • citing the appropriate numerical reference and manual title, the department rule or policy clearance letter;
    • include in the reference the specific chapter, subchapter, page number and effective date of the manual or publication source;
    • show who or what initiated the allegation; and
    • other pertinent documentation about the case.

Once all the information has been entered, the system allows users to print the information to be included in the referral packet.

2752 Expedited Referrals

Revision 24-5; Effective Nov. 1, 2024

If staff have reason to believe that the conduct of the suspected provider, person or authorized representative is serious enough to require immediate action, it may be appropriate to expedite the referral. As with routine referrals, the unit supervisor must first be consulted. An expedited referral should be made when a delay would:

  • probably result in the loss, destruction or altering of valuable evidence;
  • probably result in harm to a person;
  • probably result in significant monetary loss to the Texas Health and Human Services Commission (HHSC) that would probably not be recoverable; or
  • hinder an investigation or criminal prosecution of the alleged offense.

In these situations, the case is immediately referred to the HHSC Medicaid Program Integrity Unit at 800-436-6184 or ReportTexasFraud.com before the referral packet is produced. The HHSC representative instructs staff as to what portions of the required information should be completed and sent.

2753 Referral of Potential Fraud

Revision 24-3; Effective Nov. 1. 2024

If the unit supervisor determines that the criteria for fraud exists, a fraud referral to the Texas Health and Human Services Commission (HHSC) Medicaid Program Integrity Unit is initiated even if the potential fraud does not affect Title XIX funds. Mail the referral packet to:

Office of Inspector General
Mail Code 1361
P.O. Box 13247
Austin, TX 78708-5200

HHSC is responsible for ensuring that all pertinent information is obtained and may request more information later. Providing requested material to the HHSC does not constitute a confidentiality violation. Staff in that division conduct an analysis and collect data to create a complete picture of the alleged incident.

After referring the case to HHSC, no other action is necessary. Continue to maintain the case as usual. HHSC staff should preserve a professional working relationship with the provider, person or authorized representative while the fraud referral is being investigated. However, for the duration of the investigation, staff must not discuss the alleged violation with unauthorized personnel. This prevents the possibility of interference with the investigation.