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4310 Introduction
Revision 17-1; Effective March 15, 2017
Emergency response services (ERS) are provided through an electronic monitoring system. This system is for use by functionally impaired adults who live alone or who are functionally isolated in the community. In an emergency, the individual can press a call button to signal for help. The electronic monitoring system, which has a 24-hour, seven-day-a-week monitoring capability, helps ensure that the appropriate person or service agency responds to an alarm call from an individual.
ERS can be delivered to individuals with a landline telephone or in some areas may be available to individuals with cellular phone service or Voice Over Internet Protocol (VOIP). The provider agency choice list designates which ERS providers in the contracted service area are able to accommodate applicants who elect to receive ERS without a landline telephone. The rates for the service are the same regardless of the ERS delivery mechanism (e.g., cellular, landline, VOIP).
4311 Program Definitions
Revision 17-1; Effective March 15, 2017
The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise:
Alarm call — A signal transmitted from the equipment to the provider's response center indicating that the individual needs immediate assistance.
Call button — An electronic device that, when pressed, triggers an alarm to the response center to alert the provider that an individual needs immediate assistance. The device may be held in the hand, worn around the neck, hung on a garment or kept within the individual's reach.
Installer — A volunteer, a subcontractor or an employee of a provider who connects, maintains or repairs the equipment.
Monitor — A volunteer, subcontractor or an employee of a provider who monitors Emergency Response Services (ERS) and ensures that an alarm call is responded to immediately.
Responder — A person designated by an individual to respond to an emergency call activated by the individual. A responder may be a relative, neighbor or a volunteer.
Response center — The site where a provider's ERS monitoring system is located.
Subcontractor — An organization or individual who delivers a component of ERS for the provider for a fee and is not an employee or volunteer of the provider.
4312 Eligibility and Referral Procedures
Revision 17-1; Effective March 15, 2017
4312.1 Eligibility
Revision 24-1; Effective March 1, 2024
To be eligible for emergency response services, a person must meet the functional need criteria set by the Texas Health and Human Service Commission (HHSC) and meet the following requirements:
- live alone, be alone routinely for eight or more hours each day, or live with an incapacitated person who could not call for help or otherwise help the client in an emergency;
- be mentally alert enough to operate the equipment properly, in the judgment of the HHSC case worker;
- have a phone with a private line, if the system requires a private line to function properly;
- be willing to sign a release statement that allows the responder to make a forced entry into the person’s home if asked to respond to an activated alarm call and has no other means of entering the home to respond; and
- live in a place other than a skilled institution, assisted living facility, foster care setting, or any other setting where 24-hour supervision is available.
The eight hours mentioned in the requirement above of the rule does not have to be continuous, provided the person is alone at least eight hours in each 24-hour period. Even if the person has an attendant, consider the person alone.
If the provider is unable to complete installation, inform the person that installation of ERS equipment is pending for the reasons stated by the provider. If the person is unable or unwilling to make the needed modifications, explore other community resources to determine if these could be used to complete the needed modifications. If none are available, services may then be denied using termination code "other." Document the reason in the case record.
Review 3000, Eligibility for Services, for additional eligibility requirements.
The person is not eligible for emergency response services if they:
- abuse the service by activating:
- four false alarms which result in a response by fire department, police or sheriff, or ambulance personnel within a six-month period; or
- twenty false alarms of any kind within a six-month period; or
- is admitted to a skilled institution, personal care home, foster care setting, or any other setting where 24-hour supervision is available; and
- in the case worker's judgment, is no longer mentally alert enough to operate the equipment properly in situations including but not limited to:
- damages the equipment;
- disconnects the equipment and has received two warnings that are documented in the case record; or
- refuses to participate in the monthly systems checks; or
- is away from the home or is unable to participate in the service delivery for a period of three consecutive months or more.
Related Policy
26 Texas Administrative Code (TAC) Section 271.95
26 TAC Section 271.155(d)
4312.2 Referral Process
Revision 18-2; Effective November 19, 2018
A provider must accept all HHSC referrals. A case worker makes a routine referral on Form 2101, Authorization for Community Care Services, or makes a negotiated referral by phone and Form 2101.
The case worker gives eligible applicants an explanation of the service. He explains that applicants/individuals are required to:
- participate in the service delivery requirements; and
- the case worker reviews Attachment 2307-B, ERS Eligibility Criteria and Responsibilities, with the individual, which includes a statement allowing the responder to enter the participant's home, by force if necessary, to assist the participant.
The case worker follows procedures as outlined in 3000, Eligibility for Services.
4313 Case Management Duties Related to Emergency Response Services (ERS)
Revision 17-1; Effective March 15, 2017
If the applicant/individual appears to be in need of ERS and wants to receive ERS, the case worker determines if the applicant/individual meets the general criteria for participating in ERS.
If eligible for ERS, the case worker shares the regional list of all ERS providers and encourages the applicant to choose the most economical alternative for service provision. The applicant/individual selects a provider from the list of providers. If the applicant/individual has no preference, the case worker refers the applicant to the provider with the lowest rate. If more than one provider has the same lowest rate, the case worker makes the referral by rotation of providers. If the individual is currently receiving services from a provider that does not have the lowest rate, but is not satisfied with that provider, the case worker should encourage the individual to choose another provider. The individual should not be encouraged to choose another provider just because it has a lower rate.
The case worker may assist the individual or the provider in identifying potential responders, and in periodically updating the information the provider maintains in its files on responders and other emergency numbers. The case worker must not be an emergency responder for the individual.
HHSC rules require the ERS provider to notify the case worker no later than the next HHSC workday of alarms, other individual emergencies or changes in the individual's behavior or condition that preclude ERS.
At least annually, the case worker must review the list of responders provided to the provider to ensure the list is current. During the course of the services, the case worker and the provider have the joint responsibility of keeping each other informed of changes or problems.
Report to the contract manager any provider tendency or pattern of designation of emergency personnel as respondents. Advise the individual that he is responsible for any charges assessed by emergency personnel if they are summoned to the individual's home for a non-medical emergency.
4320 Service Delivery Requirements
Revision 17-1; Effective March 15, 2017
4321 Service Initiation
Revision 21-2; Effective June 1, 2021
When an Emergency Response Service (ERS) provider receives a copy of Form 2101, Authorization for Community Care Services, and the provider packet, they will initiate services.
After receiving the packet, the ERS provider will:
- contact the participant to make an appointment to install the emergency response home unit equipment; and
- prepare a participant file, which includes applicable provider agency forms.
Note: In addition to requesting the applicant’s or recipient’s information, the provider will also complete a home entry release statement, ownership of equipment statement, and complaint procedure form.
If a different service initiation date is required, the provider must contact Community Care Services Eligibility (CCSE) staff to negotiate the new service initiation date by which services must begin.
Evaluate if an alternative service or other resources are available to meet the person’s needs. Instruct the provider to retain the authorization and initiate services as soon as possible or request the return of the written referral packet.
Related Policy
Content of Referral Packets, Appendix XIII
4322 Reserved for Future Use
Revision 22-2; Effective June 1, 2022
4323 Reserved for Future Use
Revision 22-2; Effective June 1, 2022
4324 Provider Follow-Up Procedures
Revision 17-1; Effective March 15, 2017
The provider notifies the case worker of service initiation as outlined in 4321, Service Initiation.
The provider maintains ongoing communication with the case workers and the regional contract manager. He discusses individual-specific issues with the case worker, and contract management issues (overall service delivery, policies and procedures) with the regional contract manager.
4325 Selection of Providers and Provider Changes
Revision 22-2; Effective June 1, 2022
Each region maintains a list of all Emergency Response Services (ERS) providers. The list includes:
- vendor number;
- geographic areas served; and
- rate(s).
This information is given to the recipient to assist in making an informed choice. The recipient must select an ERS provider from the regional list. If the recipient does not have a preference, refer the recipient to the provider with the lowest rate. If there is more than one provider with the same lowest rate, refer to the next provider on a rotating basis.
The recipient must contact CCSE staff to request a provider change. CCSE staff determine:
- the issue or reason for the change request;
- if the issue can be addressed without changing providers; and
- if the provider will agree to the transfer.
Before processing a transfer, try to resolve the recipient’s concerns with the current provider.
If the issue with the provider is based on the recipient's failure to comply with the service plan, convene an interdisciplinary team (IDT) meeting to discuss the issues. If services are not terminated due to the recipient’s failure to comply with the service plan, authorize a transfer if necessary to address the recipient's concerns or if the recipient insists on changing providers.
Have the recipient select another provider and process the transfer. Coordinate the date the current provider will end services and the date the new provider will begin services. An ERS provider may receive payment for the month of service regardless of the number of days services were provided in the month services were terminated. During a transfer of ERS services, make every effort to end the service of the first provider on the last day of the month and begin service of the second provider on the first day of the following month. Coordination of the end and begin dates reduces the need for payment of services to a second ERS provider for the same calendar month.
Related Policy
Suspension and Termination of Services, 4340
4330 Service Delivery
Revision 17-1; Effective March 15, 2017
4331 Reserved for Future Use
Revision 22-2; Effective June 1, 2022
4332 System Checks
Revision 22-2; Effective June 1, 2022
An ERS recipient must be able to participate in monthly system checks. The monthly system check is to ensure that the recipient can successfully make an alarm call and that the equipment works properly.
If a provider is unable to complete a system check during a calendar month, they must notify CCSE staff in writing.
Once notified that the provider is unable to complete a system check, convene an IDT to evaluate the situation. Determine if the recipient continues to be appropriate for the service. If continuing services, complete and return Form 2067, Case Information. If terminating services, complete Form 2101, Authorization for Community Care Services.
Allow the authorization for ERS to remain effective if the recipient is still eligible for the service, but is unable to participate in a monthly system check.
Ensure the recipient's authorization does not exceed three consecutive billing months during which the recipient is unable to participate in the monthly system checks.
4333 Equipment Malfunction
Revision 22-2; Effective June 1, 2022
A provider must contact the recipient by the next day after learning of any equipment failure. They must replace the equipment if the recipient is available within one working day or by the end of the third day if the recipient is not available the first working day.
The provider must ensure the equipment is functioning properly and that each recipient receives services during the entire authorization period.
The following people may report equipment malfunctions to the provider:
- recipient;
- recipient's family members;
- recipient's responders;
- CCSE staff; and
- monitors.
Providers:
- Send the installer to the recipient's home to repair or replace the equipment as equipment malfunctions are reported.
- Keep a record of each equipment malfunction in the provider's files.
- Must visit a recipient's home to check the equipment within five working days after the equipment has registered five or more "low battery" signals in a 72-hour period.
- They must replace a defective battery during the visit.
- Must respond to "low battery" signals received from the recipient's equipment.
- Provider staff must contact the recipient by phone after receiving a "low battery" signal to determine if the "low battery" could be caused by an accident, such as the unit having been unplugged.
- If the "low battery" signals continue, the provider must send a staff member to check, and repair or replace the recipient's ERS equipment within five working days after the receipt of the fifth "low battery" signal.
4340 Suspension and Termination of Services
Revision 22-2; Effective June 1, 2022
An interdisciplinary team (IDT) meeting may be called by CCSE staff or provider staff if monthly system checks are unsuccessful or a recipient or someone in their home engages in illegal discrimination against a provider staff or HHSC staff. If services should continue, send Form 2067, Case Information, to notify the provider. If services will be terminated because of the IDT, send Form 2101, Authorization for Community Care Services, to terminate services.
Report any changes involving the recipient to the provider. (Example: hospitalization, change of residence, or visits with relatives.)
A provider may leave ERS equipment in a recipient's home and continue service delivery when the recipient has temporarily entered an institution. The provider must suspend services if the recipient has been in the institution for more than 120 consecutive days. The provider is eligible for payment if the system checks are conducted during the 120-day period.
The provider must request termination of services when the recipient is no longer competent enough to operate the equipment properly. Situations include, but are not limited to, when the recipients:
- damages the equipment;
- disconnects the equipment and has received two warnings that are documented in the case record; or
- refuses to participate in the monthly system checks.
Providers:
- Must document the inability to test the home unit in the recipient’s case file.
- Request the installer remove the equipment from the recipient’s home after CCSE staff authorize service termination.
- May leave ERS equipment in a recipient’s home and continue services until the end of the month the service authorization expires.
- Receives payment for the month the service authorization ends, if:
- monitoring continues until the equipment is picked up; and
- the equipment is tested during the same calendar month or at the time of pickup.
- May be paid for the last month of service if ERS is terminated, regardless of how many days of service were provided in that month, if the provider has complied with ERS requirements.
The recipient is not liable for payment for lost or damaged equipment.
4341 Interdisciplinary Team (IDT) Meeting
Revision 22-2; Effective June 1, 2022
CCSE staff or the provider staff will convene an IDT meeting as needed. A meeting should be called for situations where the provider is unable to resolve issues with the recipient. CCSE staff must participate in the IDT meeting to assist in resolving issues. The IDT meeting could result in continuation or discontinuation of services. If applicable, policy relating to failure to comply with the service plan must be considered.
4350 Reserved for Future Use
Revision 22-2; Effective June 1, 2022
4351 Advertising and Solicitation
Revision 17-1; Effective March 15, 2017
HHSC may investigate complaints of solicitation or coercion of individuals. Validated complaints may lead to adverse actions or termination of contracts. The ERS provider is in violation of the ERS contract if the provider employs a person:
- who is paid money each time he recruits a new Medicaid recipient; or
- whose sole responsibility is recruitment, regardless of how he is compensated.
The ERS provider may have an employee who is responsible for recruitment in addition to other assignments, as long as he is paid a regular salary and does not receive bonuses or anything that could be construed as a bonus for recruitment of Medicaid recipients.
4352 Disclosure of Previous Employment and Certification
Revision 17-1; Effective March 15, 2017
If a former or current HHSC employee or former or current council member or their relatives are an officer, director, owner or employee, the commissioner of HHSC or designee must approve the contract or contract renewal.
4353 Reserved for Future Use
Revision 22-2; Effective June 1, 2022
4360 Reassessment
Revision 17-1; Effective March 15, 2017
Reassess for eligibility within 12 months of the last functional assessment for services. Call or make a home visit to re-determine the individual's eligibility for ERS. During the home visit, ask the individual to explain how to initiate an alarm call. Evaluate whether the individual continues to be sufficiently mentally alert to operate the equipment. (See 4312.1, Eligibility.)
If the individual continues to be eligible and there are no changes, do not send anything to the provider. If services are terminated, coordinate the effective date of termination to match on Form 2065-A, Notification of Community Care Services, and Form 2101, Authorization for Community Care Services, to allow the individual 12 days prior notice.