4600, Primary Home Care and Community Attendant Services

4610 Primary Home Care (PHC) and Community Attendant Services (CAS) Contracting

Revision 17-1; Effective March 15, 2017

PHC and CAS provide in-home personal attendant services (PAS) to individuals eligible under Title XIX Medicaid or under §1929(b)(2)(B) of the Social Security Act, respectively. Both programs require that recipients have a need for assistance with personal care tasks. Providers delivering PAS must meet all of the requirements in 40 Texas Administrative Code §47.11, Contracting Requirements.

For information on the Title XX PHCP program, see Section 4400, Family Care Services.

 

4620 Personal Attendant Services Description

Revision 17-1; Effective March 15, 2017

Primary Home Care and Community Attendant Services provide non-technical attendant services to eligible individuals who have a medical condition resulting in a functional limitation in performing personal care. Attendants help individuals with activities of daily living, such as bathing, grooming, meal preparation and housekeeping. Attendants are trained and supervised by non-medical personnel.

 

4621 Allowable Tasks

Revision 21-4; Effective December 1, 2021

Personal attendant services (PAS) that may be delivered under CAS and PHC include the following tasks.

Personal care tasks related to the care of the person's physical well-being, including:

  • Bathing:
    • drawing water in sink, basin or tub;
    • hauling or heating water;
    • laying out supplies;
    • assisting in or out of tub or shower;
    • sponge bathing and drying;
    • bed bathing and drying;
    • tub bathing and drying; and
    • providing standby assistance for safety.
  • Dressing:
    • dressing the person;
    • undressing the person; and
    • laying out clothes.
  • Meal preparation:
    • cooking a full meal;
    • warming up prepared food;
    • planning meals;
    • helping prepare meals; and
    • cutting person's food for eating.
  • Feeding or eating:
    • spoon-feeding;
    • bottle-feeding;
    • assisting with using eating and drinking utensils and adaptive devices, not including tube feeding; and
    • providing standby assistance or encouragement.
  • Exercise:
    • walking with the person.
  • Grooming:
    • shaving;
    • brushing teeth;
    • shaving underarms and legs, upon request;
    • caring for nails; and
    • laying out supplies.
  • Routine hair or skin care:
    • washing hair;
    • drying hair;
    • assisting with setting, rolling, or braiding hair, not including styling, cutting, or chemical processing of hair;
    • combing or brushing hair;
    • applying nonprescription lotion to skin;
    • washing hands and face;
    • applying makeup; and
    • laying out supplies.
  • Assistance with self-administration of medication:
    • reminding person to take a medication at the prescribed time;
    • opening and closing a medication container;
    • pouring a predetermined quantity of liquid to be ingested;
    • returning a medication to the proper storage area;
    • assisting in reordering medications from the pharmacy; and
    • administration of any medication when the person has the cognitive ability to direct the administration of their medication and would self-administer if not for a functional limitation.
  • Toileting:
    • changing diapers;
    • changing colostomy bag or emptying catheter bag;
    • assisting on or off bedpan;
    • assisting with the use of a urinal;
    • assisting with feminine hygiene needs;
    • assisting with clothing during toileting;
    • assisting with toilet hygiene, including the use of toilet paper and washing hands;
    • changing external catheter;
    • preparing toileting supplies and equipment, not including preparing catheter equipment; and
    • providing standby assistance.
  • Transfer:
    • non-ambulatory movement from one stationary position to another, not including carrying;
    • adjusting or changing the person's position in a bed or chair (positioning); and assisting in rising from a sitting to a standing position.
  • Ambulation:
    • assisting in positioning for use of a walking apparatus;
    • assisting with putting on and removing leg braces and prostheses for ambulation;
    • assisting with ambulation or using steps;
    • assisting with wheelchair ambulation; and
    • providing standby assistance.

Home management tasks that support the person's health and safety, including:

  • Cleaning:
    • cleaning up after the person's personal care tasks;
    • emptying and cleaning the person's bedside commode;
    • cleaning the person's bathroom;
    • changing the person's bed linens and making the person's bed;
    • cleaning floor of living areas used by person;
    • dusting areas used by person;
    • carrying out the trash and setting out garbage for pick up;
    • cleaning stovetop and counters;
    • washing the person's dishes; and
    • cleaning refrigerator and stove.
  • Laundry:
    • doing hand wash;
    • gathering and sorting;
    • loading and unloading machines in residence;
    • using laundromat machines;
    • hanging clothes to dry; and
    • folding and putting away clothes.
  • Shopping:
    • preparing a shopping list;
    • going to the store and purchasing or picking up items;
    • picking up medication; and
    • storing the person's purchased items.
  • Escort:
    • accompanying the person outside the home to support the person in living in the community;
    • arranging for transportation, not including direct person transportation;
    • accompanying the person to a clinic, doctor's office, or location for medical diagnosis or treatment; and
    • waiting in the doctor's office or clinic with person if necessary due to person's condition or distance from home.

CCSE staff must document a specific need for escort. If escort for medical trips occurs at least once a month, time may be allocated. To determine the weekly time allocation, divide the time by 4.33 to arrive at a weekly figure. If escort occurs more than once a week, include additional documentation explaining why the person needs escort this often. See Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, for more information.

Since escort is always determined and entered on a weekly basis, use the following examples for escort services:

Example 1: A person has a doctor’s appointment every week for one hour with their chiropractor and needs another hour transportation time to get to and from the doctor’s office. The person needs two hours total escort weekly. Enter 120 minutes weekly for escort. 

Example 2: A person has one appointment a month with their radiologist. The person needs four hours total for their monthly appointment. Formula: four hours x 60 minutes = 240 minutes. 240 minutes/4.33 = 55.43 minutes per week which rounds up to 60 minutes per week.

Monthly minutes must be divided by 4.33 (weeks per month) to obtain a weekly amount of minutes needed.

Example 3: Every month, a person sees their cardiologist two hours, general practitioner three hours, chiropractor three hours and psychologist two hours. These are all standing appointments the person sees monthly. Two hours + three hours + three hours + two hours = 10 hours monthly. 10 hours x 60 minutes = 600 minutes. 600 minutes/4.33 = 138.57 minutes per week which rounds up to 140 minutes per week. Enter 140 minutes per week.

While the Service Authorization System Online (SASO) automatically rounds up in five-minute increments, services are allotted and delivered in 30-minute increments so the person will actually receive 150 minutes or 2 ½ hours a week.

Example 4: The person sees a therapist every other Friday (bi-weekly) for 2 1/2 hours including travel time. 2 1/2 hours x 60 minutes = 150 minutes. 150 minutes x 2.17 Fridays per month = 325.50 minutes total per month. 325.50 minutes per month /4.33 weeks per month = 75.17 minutes per week which rounds up to 80 minutes. Enter 80 minutes per week.

Bi-weekly amounts must be multiplied by 2.17 to obtain a monthly amount, which can then be divided by 4.33 to obtain a weekly amount.

Example 5: The person has been in a car accident and has a large need for escort. They see a chiropractor three times a week for one hour each time, a physical therapist three times a week for an hour each time, a psychiatrist bi-weekly for two hours, a pain management specialist bi-weekly for two hours, a general practitioner two hours per month and a cardiologist once a month for three hours.

In this example, no action is needed for the chiropractor and physical therapist as their times are already in the weekly amounts. The conversions needed apply to the bi-weekly and monthly visits, which need to be converted to weekly amounts and then all added together.

Weekly: 6 hours x 60 minutes = 360 minutes

Bi-weekly: 4 hours x 60 minutes x 2.17 = 520.80/4.33 = 120.28 (per week)

Monthly: 5 hours x 60 minutes = 300 minutes/4.33 = 69.28 (per week)

360 + 120.28 +69.28 = 549.56 minutes per week, which  rounds to 550 minutes per week.

Escort may also include accompanying the person on non-medical trips such as the grocery store, paying bills, pharmacy, hair stylist, barber or social events. No more time for escort for non-medical trips is allocated to the person's service plan on Form 2060. The person may elect to receive escort in place of assistance with household or personal care on a day that best meets their needs. The time used to provide the escort task must not exceed the total time purchased for attendant care.

This service does not include the direct transportation of the person by the attendant. Transportation is available through the Medical Transportation Program (MTP). Contact the regional MTP manager about the person’s referral to this program.

Related Policy

Contracting to Provide Primary Home Care Services Handbook

 

4622 Excluded Tasks

Revision 17-1; Effective March 15, 2017

Services that must be provided by a person with professional or technical training may not be purchased through Title XIX personal attendant services. These excluded services include, but are not limited to:

  • insertion and irrigation of catheters;
  • irrigation of body cavities;
  • application of sterile dressings involving prescription medications and aseptic techniques;
  • tube feedings;
  • injections;
  • administration of medication; or
  • any other skilled services identified by the Texas Health and Human Services Commission nurse.

Services that maintain an entire family or household, unless the entire household receives the service, are also excluded. Examples include:

  • cleaning the floor and furniture in areas that the individual does not occupy or use;
  • preparing meals for the entire family or household;
  • laundering clothing or bedding that the individual does not use (for example, laundering clothing and bedding for the entire household rather than laundering only the individual's clothing and bed linens); or
  • shopping for groceries or household items the individual does not need for health and maintenance. Note: An attendant may shop for items the individual needs and the rest of the household also uses.

 

4623 Personal Attendants

Revision 21-4; Effective December 1, 2021

The person's or provider's choice of attendants is not limited unless:

  • CCSE staff specify a particular attendant should not be employed by the provider; or
  • a supervisor, CCSE staff or regional nurse determines the attendant is not providing adequate care.

Personal attendant services tasks may be performed by an unlicensed person who is 18 or older and has demonstrated competency to perform the tasks assigned by the supervisor. Additionally, tasks may be performed by an unlicensed person who is:

  • under 18 years old and a high school graduate; or
  • enrolled in a vocational educational program and has demonstrated competency to perform the tasks assigned by the supervisor.

The attendant cannot be a legal or foster parent of a minor child who receives the service, or the service recipient's spouse. 

Related Policy 

Who Cannot Be Hired as the Paid Attendant, 2514

 

4624 Priority Status Determination

Revision 17-1; Effective March 15, 2017

Priority status is determined by evaluating the effect that going without certain critical purchased tasks would have on an individual.

An individual with priority status may receive no more than 42 hours of service per week. An individual without priority status may receive no more than 50 hours of service per week.

The community care case worker establishes a priority status for each individual based on the functional assessment. An individual is considered to have priority status if the following criteria are met:

  • The individual is completely unable to perform one or more of the following activities without hands-on assistance from another person:
    1. transferring himself into or out of bed or a chair or on off a toilet;
    2. feeding himself;
    3. getting to or using the toilet;
    4. preparing a meal; or
    5. taking self-administered prescribed medications.
  • During a normally scheduled service shift, no one is readily available who is capable and who is willing to provide the needed assistance other than the attendant.
  • The community care case worker determines that there is a high likelihood the individual's health, safety, or well-being would be jeopardized if services were not provided on a single given shift.

Each eligible individual may receive up to 50 hours of personal attendant services per week (42 hours per week for an individual with priority status). For additional information regarding the determination of priority status, see Section 2540, Priority Status Individuals.

 

4630 Eligibility

Revision 17-1; Effective March 15, 2017

For eligibility policy not contained in this section, see:

 

4631 Residence

Revision 17-1; Effective March 15, 2017

40 Texas Administrative Code §48.2918(b). To receive services, the applicant/client must reside in a place other than:

(1) a hospital;
(2) a skilled nursing facility;
(3) an intermediate care facility;
(4) an assisted living facility;
(5) a foster care setting;
(6) a jail or prison;
(7) a state school;
(8) a state hospital; or
(9) any other setting where sources outside the primary home care program are available to provide personal care.

Title XIX personal attendant services (PAS) cannot be authorized if the individual lives in a home licensed as a personal care home by the Texas Department of State Health Services. If the home is not a licensed personal care home, services may be authorized as follows:

  • If three or fewer persons live in the home, the proprietor can be the PAS attendant for the individual(s) who resides there. The individual may not receive both PAS and Adult Foster Care.
  • If the home provides only room and board to four or more persons living in the home, it does not require licensure as a personal care home. PAS services can be authorized for individuals in this setting, but the proprietor, his agent or employee cannot be the attendant for individuals who reside in the home. The case worker must specify this on Form 2101, Authorization for Community Care Services.

Title XIX PAS services can be provided to a private pay applicant/individual living in a residential care facility (whether or not contracted with HHSC) under the following conditions. The case worker:

  • applies the unmet need policy on a task-by-task basis, not duplicating services. Facilities provide varying degrees of assistance and tasks purchased should not be a task provided by the facility.
  • must closely monitor the case to determine if the individual is receiving additional services from the facility. Service plans must be adjusted to avoid duplication of services/tasks.

If the individual begins receiving Residential Care (RC) through HHSC, the Title XIX PAS service is terminated effective no later than the date RC services begin.

 

4632 Financial Eligibility

Revision 17-1; Effective March 15, 2017

40 Texas Administrative Code §48.2918(a). To be eligible for primary home care or community attendant (CA) services, the applicant/client must:

(1) be eligible for Medicaid in a community setting or be eligible under the provisions of the Social Security Act, §1929(b)(2)(B)

Before referring the individual to Primary Home Care (PHC), verify Medicaid eligibility for the month that financial/functional eligibility is determined.

To receive PHC services, applicants/individuals must be receiving benefits that include full Medicaid eligibility. Case workers must consult the Texas Integrated Eligibility Redesign System (TIERS) to determine if an applicant or individual is receiving full Medicaid benefits. Note: Residence outside an institution is also an eligibility criterion so institutional type programs will not be eligible for PHC. See Section 7110, TIERS Inquiries, and Appendix XIV, SAVERR/TIERS Type Program Chart, for a description of all TIERS type programs.

Individuals obtain financial eligibility for Community Attendant Services (CAS) by applying to Medicaid for the Elderly and People with Disabilities. CAS eligibility can be confirmed by checking TIERS.

See Section 2347, Texas Medicaid Estate Recovery Program (MERP), when processing CAS applications.

 

4633 Functional Eligibility

Revision 17-8; Effective September 1, 2017

40 Texas Administrative Code (TAC) §48.2918(a). To be eligible for primary home care or community attendant (CA) services, the applicant/client must:

(2) meet the minimum functional need criteria as set by the department. The department uses a standardized assessment instrument to measure the client's ability to perform activities of daily living. This yields a score, which is a measure of the client's level of functional need. The department sets the minimum required score for a client to be eligible, which the department may periodically adjust commensurate with available funding. The department will seek stakeholder input before making any change in the minimum required score for functional eligibility.

Title XIX personal attendant services (PAS) eligibility only requires that an individual have a need for assistance with personal care. However, the provider is not allowed to provide services unless at least one personal task is authorized, scheduled and delivered by the provider.

Example: An applicant requests Primary Home Care (PHC) and scores 30 on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide. However, the only personal care task the individual needs is meals service, which is being provided via congregate meals. Therefore, PHC services cannot be approved.

Applicants and individuals must score at least 24 on Form 2060, and require at least six hours of service per week. An individual requiring fewer than six hours of service per week may be eligible if the individual:

  • requires primary home care or community attendant services to provide respite care to the caregiver;
  • lives in the same household as another individual receiving primary home care, community attendant services, or family care;
  • receives one or more of the following services (through the department or other resources):
    • congregate or home-delivered meals;
    • assistance with activities of daily living from a home health aide;
    • day activity and health services; or
    • special services to persons with disabilities in adult day care;
  • receives aid-and-attendance benefits from the Veterans Affairs; or
  • is determined, based upon the functional assessment, to be at high risk of institutionalization without primary home care or community attendant care services.

See Section 4651, Assessing the Individual's Needs, for casework procedures involved in establishing functional need.

 

4634 Practitioner's Statement of Medical Need

Revision 17-1; Effective March 15, 2017

40 Texas Administrative Code §48.2918(a). To be eligible for primary home care or community attendant (CA) services, the applicant/individual must:

(3) have a medical need for assistance with personal care.
(A) The individual's medical condition must be the cause of the individual's functional impairment in performing personal care tasks.
(B) Persons diagnosed with mental illness, mental retardation, or both, are not considered to have established medical need based solely on such diagnosis. The diagnoses do not disqualify an individual for eligibility as long as the individual's functional impairment is related to a coexisting medical condition;
(4) have a signed and dated practitioner's statement that includes a statement that the individual has a current medical need for assistance with personal care tasks and other activities of daily living.

The need for Primary Home Care (PHC) and Community Attendant Services (CAS) must be documented by a practitioner's statement of medical need. As part of the determination of eligibility for Title XIX personal attendant services (PAS), case workers must verify that applicants have a medically related health problem that causes a functional limitation in performing personal care.

See Section 4661, Receipt of the Practitioner's Statement of Medical Need, for procedures to determine medical need.

 

4640 Retroactive Payments

Revision 17-1; Effective March 15, 2017

State law requires that home and community support services agencies that provide personal attendant services (PAS) be licensed by the Texas Health and Human Services Commission (HHSC). It is possible for a Medicaid-eligible person to begin receiving services before HHSC receives a referral for Primary Home Care (PHC). The information below states the procedures case workers, HHSC nurses and providers must use when processing an application for retroactive payment.

 

4641 Provider's Role

Revision 17-1; Effective March 15, 2017

A provider who delivers attendant care services to a non-Medicaid individual on a private pay basis risks losing revenue unless an agreement exists for the individual to pay the provider if he is not determined eligible. A provider may bill non-Medicaid individuals for services delivered before the time the individual is eligible for retroactive payment by the Texas Health and Human Services Commission (HHSC). However, federal requirements do not allow providers to bill Medicaid recipients for Medicaid reimbursable services.

40 Texas Administrative Code (TAC) §47.85(c)(1) ─ The provider agency may be reimbursed for services provided before the date a completed, signed, and dated copy of DHS' Application for Assistance –Aged and Disabled form is received: (A) for up to three months for a person who does not have Medicaid eligibility at the time of the request for retroactive payment; and (B) for an indefinite period for a person who is Medicaid eligible at the time of the request for retroactive payment.

The three month prior period applies to non-Medicaid individuals who apply for Primary Home Care (PHC) services using retroactive payment procedures. The three month prior period does not apply to Medicaid recipients who request PHC services using retroactive payment procedures. For Medicaid recipients, HHSC can reimburse a provider for a retroactive payment period beyond three months as long as the services are Medicaid reimbursable and the individual was Medicaid eligible when the services were received. Medicaid recipients do not complete a written application (Form H1200, Application for Assistance – Your Texas Benefits) for retroactive or ongoing PHC services.

A request for retroactive payment can be made by the individual, provider or interested party by contacting Community Care Services Eligibility (CCSE) intake staff. CCSE staff who receive requests for retroactive payment use current intake procedures for a routine request for in-home care services. The beginning date of services cannot be prior to the practitioner's signature date on Form 3052, Practitioner's Statement of Medical Need.

40 TAC §47.85(e)  Pre-initiation activities. The provider agency must complete the pre-initiation activities described in §47.45(a) of this chapter (relating to Pre-Initiation Activities).

(f) Intake referral. On the day that the provider agency completes the pre-initiation activities, the provider agency must contact the local DHS office by telephone and make an intake referral by providing DHS information on the person to start the eligibility process.
(g) Service initiation. The provider agency must not begin to provide services to the person before the date the provider agency completes the pre-initiation activities and processes the intake referral as described in subsections (e) and (f) of this section.

Within seven days after the date the provider processes the intake referral, the provider must submit the written request for retroactive payment to the case worker. The written request must include the:

  • copy of the service plan;
  • copy of Form 3052;
  • retroactive payment information, including the:
    • name of the provider;
    • contact information for the individual;
    • date services were started;
    • tasks provided to the individual including both tasks allowed and not allowed by the PHC program;
    • actual service hours that were provided per week, including hours allotted to allowed tasks and tasks not allowed by the PHC program; and
    • cost per hour of service charged to the individual.

If the provider billed the individual for tasks that are not Medicaid reimbursable, the provider must inform the case worker so he will know how many hours to deduct from the payment made by HHSC to the provider.

 

4642 Case Worker's Role

Revision 17-1; Effective March 15, 2017

The case worker must respond to the request for services according to the time frames in Section 2320, Case Worker Response, and make the home visit to assess the applicant for ongoing services.

The case worker is not responsible for determining functional need during the retroactive period. Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, is completed to determine ongoing functional eligibility but does not affect eligibility for retroactive payments. Also, the case worker does not apply the unmet need policy to the retroactive period. See Section 2433, Determining Unmet Need in the Service Arrangement Column.

 

4643 Applicant Approved for Retroactive Payment and Continued Services

Revision 17-1; Effective March 15, 2017

If the applicant is Medicaid eligible or was Medicaid eligible at service initiation, the Texas Health and Human Services Commission (HHSC) will only reimburse the provider for tasks/hours/costs within the scope of the Primary Home Care (PHC) program. If the applicant is eligible for the retroactive payment period and for continued PHC services, the case worker must verify that the service plan developed by the provider contains the following information:

  • individual is receiving at least one personal care task. If there are no personal care tasks, the provider will not be reimbursed for services;
  • total amount of weekly service hours;
  • the total amount of weekly services hours are within the maximum weekly hours (50 allowed in the PHC program);
  • tasks provided are the type covered under the PHC program; and
  • cost per hour of service is equal to the non-priority rate in the PHC program. Note: Provider agencies will not determine priority status nor will they be reimbursed at the higher priority status rate for the retroactive payment period.

Determine the amount of reimbursement the applicant is eligible to receive from the provider by multiplying the cost per hour of service found in the service plan developed by the provider times the total amount of hours of approved service provided to the applicant. Include this amount on Form 2065-A, Notification of Community Care Services, to advise the applicant and the provider of the dollar amount of retroactive payment the applicant should receive from the provider.

Note: Because the individual is receiving services up to the time of the service initiation date for continued PHC services, the case worker may not know the last day services were provided during the retroactive period. The reimbursement amount may vary from the actual amount due to the applicant depending on whether the applicant paid in full, or has not paid the provider for the most recent service provided during the retroactive period.

The provider will not be reimbursed for a retroactive payment period if:

  • the applicant did not receive any personal care tasks from the provider;
  • none of the tasks provided by the provider were within the scope of the program (Example: the individual received transportation, direct administration of medications or protective supervision assistance); or
  • the applicant is determined ineligible for retroactive payment by HHSC.

The provider will not be reimbursed for amounts higher than the HHSC limits when the:

  • service plan includes more than the maximum weekly hours allowed in PHC; or
  • cost per hour of service is more than the non-priority rate.

The case worker must deduct time for any task(s) that cannot be purchased as part of PHC service from the total hours of services provided by the provider in order to determine how many hours (at the non-priority status rate) HHSC will reimburse the provider. If more than 50 hours per week were provided, the time for the non-allowable tasks should be deducted first and then the additional hours deducted to be within the 50 hour per week limit.

Send the provider a copy of the same Form 2065-A sent to the applicant to advise the provider of the amount to reimburse the applicant. Multiply the total service hours the applicant received by the cost per hour of services reported in the provider's service plan. Note: The dollar amounts used in the examples are fictitious. The current PHC rates may be verified at https://rad.hhs.texas.gov/long-term-services-supports.

Example 1:

A provider documents in the service plan that an applicant received 52 hours of service at $12.00 an hour for one week of the retroactive period. Of the total 52 service hours reported to date, three hours were for transportation. Calculate the amount the provider is paid using the following example as a guide.

52 hours minus 3 hours— — (deduct 3 hours since transportation is not an allowable task in PHC) = 49 hours

49 hours x $9.61 — — (the non-priority participating rate in PHC) = $470.89

$470.89 is the amount HHSC will pay the provider.

Document 49 hours in Item 18, Units, on Form 2101, Authorization for Community Care Services, and send it to the provider.

49 hours x $12.00 an hour (estimated private-pay rate) = $588.00. This is the amount of Medicaid-reimbursable tasks the provider must reimburse the individual.

Document $588.00 on Form 2065-A and send it to the applicant to advise him of the amount he should be reimbursed from the provider. Send a copy of Form 2065-A to the provider to advise the provider of the amount it must reimburse the individual. The provider can privately bill the individual for three hours of services determined by the case worker not to be Medicaid-reimbursable tasks.

Example 2:

A provider documents in the service plan that an applicant received 55 hours of service at $10.00 an hour for one week of the retroactive period. All of the 55 service hours were performed on Medicaid-reimbursable tasks. Calculate the amount the provider is paid using the following example as a guide.

55 hours minus 5 hours — — (deduct five hours which exceed the weekly limit allowed in PHC) = 50 hours

50 hours x $9.61 = $480.50

$480.50 is the amount HHSC will pay the provider.

Document 50 hours in Item 18, Units, on Form 2101 and send to the provider.

50 hours x $10.00 an hour = $500.00. This is the amount of Medicaid-reimbursable tasks the provider must reimburse the individual.

Document $500.00 on Form 2065-A and send it to the applicant to advise him of the amount he should be reimbursed from the provider. Send a copy of Form 2065-A to the provider to advise the provider of the amount it must reimburse the applicant.

Example 3:

A provider documents in the service plan that an applicant received 55 hours of service at $12.00 an hour for one week of the retroactive period. Of the total of 55 service hours provided, three hours were for transportation. Calculate the amount the provider is paid using the following example as a guide.

55 hours minus 3 hours for transportation — (a non-Medicaid reimbursable task) = 52 hours

52 hours minus 2 hours — (deduct two hours which exceed the weekly limit allowed in PHC) = 50 hours

50 hours × $9.61 = $480.50

$480.50 is the amount HHSC will pay the provider.

Document 50 hours in Item 18, Units, on Form 2101 and send it to the provider. Send the usual initial PHC packet to the provider for the continued service period.

50 hours x $12.00 an hour = $600.00. This is the amount of Medicaid-reimbursable tasks the provider must reimburse the applicant.

Document $600.00 on Form 2065-A and send it to the applicant to advise him of the amount he should be reimbursed from the provider. Send a copy of Form 2065-A to the provider to advise the provider of the amount it must reimburse the individual. The provider can privately bill the individual for the three hours for transportation since this is not a Medicaid-reimbursable task.

If a provider provides service to an individual during a retroactive period where all tasks/hours/costs are all within the scope of the PHC program, then the dollar amount due the individual and the provider will be the same.

Example: A provider documents in the service plan that the individual received 30 hours of allowable household and at least one personal care task per week and charged the individual $9.61 an hour non-priority participating PHC rate to provide the attendant care. Calculate 30 hours x $9.61 = $288.30. This is the amount HHSC pays the provider and is the same amount refunded by the provider to the applicant. In this example, advise both the provider and the applicant the same amount, using Form 2065-A.

Send the provider Form 2101 for the retroactive payment period with an end date the day before the beginning of the continued PHC services. Send a second Form 2101 authorizing ongoing services with the complete initial PHC packet.

 

4644 Applicant Approved for Retroactive Payment and Denied Continued Services by the Case Worker

Revision 17-1; Effective March 15, 2017

If the applicant is eligible for the retroactive period but is not financially or functionally eligible for continued Primary Home Care (PHC) services, the case worker must call the provider and notify the provider of the last day of the retroactive period and the ineligibility for ongoing services. Document the telephone call in the comments section of Form 2101, Authorization for Community Care Services, for the retroactive period.

The case worker must verify the following conditions are present in the service plan developed by the provider:

  • applicant is receiving at least one personal care task;
  • total amount of weekly service hours are within the maximum weekly hours (50 allowed in the PHC program); and
  • the tasks provided are covered within the PHC program.

The provider will not be reimbursed if no personal care task(s) were provided. The amount of reimbursement will be reduced if the:

  • service plan includes more than the 50 weekly maximum hours allowed in PHC;
  • tasks provided are not the type of tasks covered by the PHC program; or
  • cost per hour of service the provider billed the applicant is more than the Texas Health and Human Services Commission non-priority rate.

Within two business days of the decision of ongoing ineligibility, the case worker sends the applicant and the provider Form 2065-A, Notification of Community Care Services, which includes the:

  • effective date of denial of continued services, and
  • amount the provider should reimburse the applicant.

The case worker must complete and send Form 2101 to the provider for the retroactive payment period. Use the Form 2101 instructions to complete the items for the retroactive period with the following exceptions:

  • Item 4 — "Begin" date is obtained from the applicant's service plan which was developed by the provider. The begin date cannot be prior to the practitioner's signature date on Form 3052, Practitioner's Statement of Medical Need.
  • Item 5 — "End" date is the date the case worker determines the applicant ineligible for continued PHC services. The "End" date on Form 2101 must match the:
    • effective date of denial on Form 2065-A; and
    • verbal termination date for the retroactive period.
  • Item 18 — Enter the amount of service hours minus any disallowed tasks/cost/hours for services that are not Medicaid reimbursable.
  • Item 31 — Last name of Doctor of Medicine/Doctor of Osteopathic Medicine (MD/DO) = RETRO PAS
  • Item 33 — MD/DO License Number
  • Item 34 — Date of Orders

 

4645 Special Procedures for Community Attendant Services (CAS)

Revision 17-1; Effective March 15, 2017

Providers must be aware of the risk of losing revenue if attendant care services are delivered to a non-Medicaid individual. If the applicant is determined ineligible, retroactive payment will not be made by the Texas Health and Human Services Commission (HHSC).

The case worker proceeds with the referral to Medicaid for the Elderly and People with Disabilities (MEPD) upon receipt of Form H1200, Application for Assistance – Your Texas Benefits, following the CAS referral procedures.

When the eligibility decision is received from MEPD and the applicant is determined eligible, the case worker sends the HHSC nurse a copy of the pre-assessment packet from the provider and Form 3052, Practitioner's Statement of Medical Need, along with a "pending" Form 2101, Authorization for Community Care Services, for the retroactive period. The case worker enters "“Retroactive Payment Applicant"” in the comments section on Form 2101. The HHSC nurse may authorize services effective the start date of service delivery as long as it is within the three months prior to the medical effective date established by MEPD, and other conditions are met. The HHSC nurse also completes a second Form 2101 for ongoing services if the applicant is eligible for ongoing CAS. See Section 4662.1, Authorization for Routine Referrals, for procedures for ongoing authorization. The HHSC nurse sends a copy of Form 2101 for the retroactive period and a copy of Form 2101 for ongoing services to the provider and the case worker.

Within two business days of receipt of Form 2101, the case worker sends the applicant and the provider Form 2065-A, Notification of Community Care Services, for the retroactive period which includes the:

  • effective dates of the retroactive period;
  • total weekly hours of service approved; and
  • amount to be reimbursed to the applicant.

The case worker sends a second Form 2065-A to the applicant advising of ongoing services, including the effective date and the total weekly hours.

 

4646 CAS Applicant Determined Ineligible by MEPD Staff

Revision 17-1; Effective March 15, 2017

If the Community Attendant Services (CAS) applicant is determined ineligible by Medicaid for the Elderly and People with Disabilities (MEPD) staff, the case worker must:

  • immediately notify the provider that the applicant is not Medicaid eligible, advising of the date of Medicaid denial; and
  • send the applicant and provider Form 2065-A, Notification of Community Care Services, advising the denial for retroactive payment and continued services.

Note: The provider will not be reimbursed for retroactive services by the Texas Health and Human Services Commission and the provider does not have to reimburse the applicant for privately paid services.

 

4647 Notifications

Revision 17-1; Effective March 15, 2017

For all decisions on retroactive payments, both the applicant and the provider must be sent Form 2065-A, Notification of Community Care Services. The applicant must also be notified of eligibility or ineligibility for ongoing services on Form 2065-A. The provider is sent Form 2101, Authorization for Community Care Services, authorizing the retroactive services and Form 2101 for ongoing services, if the applicant is eligible.

 

4647.1 Notifications to Providers

Revision 17-1; Effective March 15, 2017

For all decisions on retroactive payments, send the provider a copy of Form 2065-A, Notification of Community Care Services. For any service authorizations, send the provider Form 2101, Authorization for Community Care Services. If, during the retroactive determination process for Primary Home Care the applicant is determined ineligible for continued services, the case worker must call the provider immediately to advise of the applicant's ineligibility. The case worker documents the telephone call in the comments section of Form 2101, authorizing the retroactive period.

 

4647.2 Notifications to Applicants

Revision 17-1; Effective March 15, 2017

Applicants must be notified of all decisions on Form 2065-A, Notification of Community Care Services, within two business days of the date of the decision. If the applicant is determined eligible for retroactive and continued services, send two Form 2065-As. Form 2065-A for the retroactive period must contain the effective dates, type and amount of service authorized and the amount of reimbursement the applicant should receive for the services the provider delivered during the retroactive period. The second Form 2065-A advises the applicant of the eligibility for ongoing services, including the effective date, type and amount of service authorized.

If the applicant is denied for retroactive and continued services, document in the comments section of Form 2065-A that the applicant is ineligible for continued Primary Home Care or Community Attendant Services and is not eligible for retroactive payments from the provider for the months of the retroactive period (list the actual months). Retroactive payment applicants who appeal because payment was denied by the Texas Health and Human Services Commission are not entitled to payment for continued services pending outcome of the appeal.

 

4648 Reimbursement

Revision 17-1; Effective March 15, 2017

40 Texas Administrative Code §47.85(i), Charges to persons who receive services.

(1) The provider agency may charge a person for services for which the provider agency intends to request retroactive payment, unless the person is Medicaid eligible.
(2) The provider agency must reimburse the entire amount of all payments made by the person to the provider agency for eligible services, even if those payments exceed the amount DHS will reimburse for the services, if DHS determines that the person is eligible for the Primary Home Care Program.

If the Texas Health and Human Services Commission determines the applicant is eligible for Primary Home Care or Community Attendant Services, the provider must reimburse the entire amount of all payments made to the provider for eligible services during the three months preceding eligibility, regardless of whether or not those payments exceeded the amount the provider will be reimbursed for those services.

If an applicant has a question or does not agree with the amount of reimbursement from the provider, it is up to the applicant, caregiver, authorized representative or applicant's family to advise the case worker of any discrepancies between the:

  • amount of money the case worker advised that the applicant would receive; and
  • actual amount received from the provider.

Final resolution of any disagreements between the provider, individual and/or case worker over the amount of reimbursement due the individual is resolved by the case worker's supervisor. The supervisor may consult appropriate regional support staff in an effort to reach a final decision involving reimbursement disagreements. Note: The provider must reimburse the individual within seven days of receiving payment from HHSC.

 

4650 Service Planning

Revision 17-1; Effective March 15, 2017

The case worker is responsible for all aspects of service planning for Primary Home Care (PHC), including:

  • determining the applicant's eligibility for services, as described in Section 4630, Eligibility;
  • developing a service plan based on the applicant's unmet need for service, as described in Section 2433, Determining Unmet Need in the Service Arrangement Column;
  • authorizing services and referral to a provider, as described in Section 4660, Service Authorization; and
  • providing ongoing case management for the individual.

The case worker follows the procedures for initial intakes in Section 2300, Responding to Requests for Service. The initial home visit and functional assessment are completed in accordance with Section 2400, Assessment Process. Note on the worksheet of Form 2059, Summary of Client's Need for Service, the applicant's reported medical diagnosis and functional limitations. If the individual reports only a diagnosis of mental health, intellectual disability (ID) or intellectual and developmental disability (IDD), discuss that he may not meet the medical eligibility criterion for PHC. Advise the applicant that the provider will contact his medical practitioner for additional medical information. In developing the service plan, ensure that the applicant needs at least one personal care task.

 

4651 Assessing the Individual's Needs

Revision 18-2; Effective November 19, 2018

In a face-to-face interview with the individual, conduct a functional assessment of the applicant, as described in Section 2430, Functional Assessment. The case worker may consult the Texas Health and Human Services Commission (HHSC) nurse about any issues that:

  • may impact individual health and safety; or
  • bring medical and functional eligibility into question.

If, during the process of developing the service plan, it is determined that a particular person should not be employed as the individual's attendant, the case worker documents this information on Form 2101, Authorization for Community Care Services. See Section 2514, Who Cannot Be Hired as the Paid Attendant, for additional information.

Review the service plan and explain the services to the individual. Let him know the number of hours and number of days services are to be delivered and the tasks he is authorized to receive. Inform the individual that to continue to qualify for services, he must need at least one personal care task. If the individual does not need a personal care task, Title XIX personal attendant services (PAS) cannot be authorized. The individual must also need at least six hours of services per week, unless he meets one of the criteria listed in Section 4633, Functional Eligibility. Assess the individual for Family Care Services if the criteria for Title XIX PAS are not met.

Give Form 2307, Rights and Responsibilities, and Attachment 2307-A, Family Care, Community Attendant Services and Primary Home Care Rights and Responsibilities, to all applicants. Explain that the case worker must approve changes in the service plan. Also, inform the individual that he may select another provider if he is dissatisfied with the services or attendant providing the services.

If the Primary Home Care applicant meets all eligibility criteria, send a referral packet to the provider within five business days from the face-to-face interview. This referral will prompt the provider to begin pre-initiation activities.

If the Community Attendant Services applicant meets all functional eligibility criteria, send the Application for Assistance form to Medicaid for the Elderly and People with Disabilities for the financial determination.

 

4651.1 Service Delivery Outside the Home

Revision 17-1; Effective March 15, 2017

Services may be authorized to be delivered in locations other than the individual's home.

For service delivery outside the individual’s home but within a provider agency’s contracted service delivery area:

  • The provider agency may develop a service plan that includes services regularly delivered at a location other than the individual’s home. The service plan must not exceed the weekly hours authorized on Form 2101, Authorization for Community Care Services.
  • The provider agency may deliver services outside the individual’s home when the service plan does not include the regular delivery of such services.

The provider agency:

  • may deliver services outside the individual’s home only if the individual requests such services;
  • is not required to pay for expenses incurred as a result of an attendant delivering services outside the individual’s home;
  • must make a reasonable effort to deliver services at a location other than the individual’s home when requested by the individual;
  • maintains written justification if the individual’s request was not granted; and
  • documents in the individual’s record:
    • each instance when the individual requested services at a location other than the home;
    • whether the individual’s request was granted;
    • what services were provided; and
    • where the services were delivered.

Texas Administrative Code §47.63, Service Delivery, provides the rules for Home and Community Support Services (HCSS) agencies to deliver services outside the home. The provider may develop a service plan that includes services regularly delivered at a location other than the individual's home or may deliver services at an alternate location at the individual's request. See Section 2522, Service Delivery in Alternate Locations, for additional case worker procedures.

Case workers should pay particular attention to this policy if they have disabled individuals who are working or attending school and need assistance in the workplace/school. The Social Security Administration has several programs to assist disabled persons with employment at www.socialsecurity.gov/pubs/10095.html.

Additionally, persons enrolled in the Medicaid Buy-In program will be working and may require service delivery in alternate locations.

While services may be delivered outside the home, only allowable tasks may be authorized and the provider is not required to pay for expenses incurred by attendants delivering services outside the home. Hours authorized are based solely on services that could be delivered in the home.

The case worker must send Form 2067, Case Information, to the provider with information about the individual's request for services in an alternate location and work with the individual and provider to arrange the services that will meet the individual's needs within the scope of the program.

 

4652 Types of Referrals

Revision 17-1; Effective March 15, 2017

There are two methods of referral:

  • For expedited referrals, the case worker makes the referral by oral notice and on Form 2101, Authorization for Community Care Services.
  • For routine referrals, the case worker makes the referral on Form 2101.

See Appendix IV, Workflow and Time Frames, for procedures for the different types of referrals.

 

4652.1 Routine Referrals for Primary Home Care

Revision 21-2; Effective June 1, 2021

For routine Primary Home Care (PHC) referrals, complete the following within five business days after the home visit:

  • enter the assessment information in the Service Authorization System Online Wizards (SASOW); and
  • send a referral packet to the provider.

The referral packet 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
    • referral Form 2101, Authorization for Community Care Services.

The referral packet notifies the provider to begin pre-initiation activities.

Refer PHC applicants that are mandatory STAR+PLUS members to the enrollment broker.

Related Policy

Requests for Services in STAR+PLUS Areas, 2221
Content of Referral Packets, Appendix XIII

 

4652.2 Expedited Referrals for Primary Home Care

Revision 18-1; Effective June 15, 2018

In some instances, the individual's need for services, based on the case worker's judgment, is such that delivery of services must be facilitated. When weighing whether an expedited referral is warranted, the case worker should consider the following:

  • What was the individual's assigned intake priority? In most situations, cases that require an expedited response to a request for services also require an expedited referral.
  • Is the applicant being authorized as having priority status? If so, that may indicate a need for an expedited referral.
  • Could a delay in starting services constitute a threat to the individual's health, safety or well-being? If so, an expedited referral may be needed.

The expedited referral process includes the case worker:

  • making an oral request by the next business day from the home visit that immediately begins pre-initiation activities and negotiating a date for the completion of pre-initiation activities, which must be less than 14 days;
  • following up the oral request by sending a referral packet, including Form 2101, Authorization for Community Care Services, to the provider, noting the negotiated completion date in the comments section;
  • negotiating a start of care date with the provider upon notification of a completed practitioner's statement, which must be in less than 14 calendar days; and
  • authorizing services in the Service Authorization System no later than the fifth business day after a start date has been negotiated.

The provider may only call the case worker to provide information from Form 3052, Practitioner's Statement of Medical Need, and negotiate a start-of-care date in the case of an expedited referral. The start of care for the expedited referral must be earlier than the 14-day time frame for a routine referral and cannot be before the date the practitioner signed Form 3052. The provider must send the case worker Form 3052 within seven days.

 

4652.3 Initial Referrals for Community Attendant Services

Revision 21-2; Effective June 1, 2021

For CAS referrals, complete the following within seven business days after receiving the financial eligibility determination:

  • enter the assessment information in the Service Authorization System Online Wizard (SASOW); and
  • send the provider a referral packet.

The referral packet 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
    • referral Form 2101, Authorization for Community Care Services.

Do not send a copy of the referral Form 2101 to the HHSC nurse on initial CAS cases. Send the referral packet to the provider and it is the provider's responsibility to send the required documents, including Form 3052, Practitioner's Statement of Medical Need, to the HHSC nurse.

Note: Providers have been requested to send Form 2101 with Form 3052 as a courtesy to assist with applicant identification, but this is not required.

Track the CAS referral. If the authorization Form 2101 is not received from the HHSC nurse within 30 calendar days after sending the referral Form 2101 to the provider, check with the HHSC nurse to see if the referral was received from the provider. If not, contact the provider and request Form 3052 be sent to the HHSC nurse.  Document all contacts in the case record.

Related Policy

Screening for Primary Home Care and Community Attendant Services, 2342
Workflow and Time Frames, Appendix IV
Content of Referral Packets, Appendix XIII

 

4652.4 CAS Applicants Requiring Immediate Service Delivery

Revision 17-1; Effective March 15, 2017

While a Community Attendant Services (CAS) applicant's financial eligibility is pending, the case worker may refer the individual to Family Care (FC). Unless new intakes are being placed on the interest list by the region, a referral to FC is mandatory if the individual:

  • had an intake priority of immediate or expedited; or
  • has a health condition requiring immediate service delivery in order to ensure his health and safety.

 

4653 Referral to the Provider

Revision 21-4; Effective December 1, 2021

Send the referral packet to the provider selected by the applicant or recipient. The referral packet must contain adequate information for the provider to develop the service plan based on the assessment.

The referral packet 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 Service Authorization System Online Wizards (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
    • referral Form 2101, Authorization for Community Care Services.  

All Form 2101 referrals to the provider, both initial and ongoing, must include the:

  • authorized tasks;
  • total number of authorized hours;
  • number of days the applicant or recipient requests services be delivered; and
  • relationship and name of any person designated as ‘do not hire.’

Document any of the following information in the comments section of the Form 2101:

  • any special needs of the applicant or recipient that require a specific schedule and the reason;
    Example: “<Name of person> is diabetic and requires a specific eating schedule.” or “<Name of person> requires service delivery in the afternoon due to a sleeping condition.”
  • the number of service days requested by the applicant or recipient based on the Form 2060;
    Example: "The <Name of person> requests a five-day plan."
  • the relationship and name of any person(s) designated as ‘do not hire.’
    Example: “Do not hire <spouse>, <name of spouse>, for any tasks.” or “Do not hire <daughter>, <name of daughter>, for shopping.”

Related Policy

Who Cannot Be Hired as the Paid Attendant, 2514
Service Authorizations, 2620
Referrals to the Provider, 2630
Contents of Referral Packets, Appendix XIII

 

4654 Pre-Initiation Activities

Revision 17-1; Effective March 15, 2017

The receipt of the referral packet, including Form 2101, Authorization for Community Care Services, prompts the provider to begin pre-initiation activities.

40 Texas Administrative Code (TAC) §47.45(c)(1-2) specifies that providers must complete pre-initiation activities:

  • for routine referrals, within 14 days of the later of:
    • the referral date; or
    • date the provider receives Form 2101; or
  • for expedited referrals, by the date negotiated between the case worker and provider.

Pre-initiation activities include the following:

The supervisor must develop a service delivery plan on a single document that records the following:

  • the tasks which the individual is authorized to receive;
  • the total weekly hours of service HHSC authorizes the individual to receive;
  • the service schedule, which must include as necessary, based on an individual's needs, certain time periods for the delivery of specified tasks.

The provider must obtain a complete practitioner's statement and submit for HHSC's review, as described in TAC §47.47 (relating to Medical Need Determination). This does not apply to Family Care services. For routine referrals, the provider must:

  • send a copy of the practitioner's statement to HHSC by facsimile or secured email; or
  • mail a copy of the practitioner's statement to HHSC.

For expedited referrals:

  • HHSC may send the authorization for community services form pending receipt of the practitioner's statement if the provider notifies HHSC that the provider has received a complete practitioner's statement that documents the individual's medical condition is the cause of the individual's functional impairment.
  • Upon notification of a completed practitioner's statement, HHSC and the provider will negotiate a start-of-care date.
  • The provider must send the complete practitioner's statement to HHSC within seven working days of service initiation.
  • If a complete practitioner's statement is not sent to HHSC within seven business days of service initiation, the provider is not entitled to payment from HHSC until the date HHSC receives the completed practitioner's statement. In this circumstance, HHSC will change the service initiation date to the date HHSC receives the completed practitioner's statement.
  • The signature date of the practitioner must be on or before the negotiated start-of-care date.

 

4654.1 Delays in Pre-Initiation Activities

Revision 17-1; Effective March 15, 2017

The provider must complete the pre-initiation activities within the required time frames as described in Section 4654, Pre-Initiation Activities, or document the reason(s) for a delay.

  • A provider may delay meeting the due dates only for reasons beyond its control, such as natural or other disasters. The provider must continue efforts to complete pre-initiation activities and set a date, if possible, for completion of pre-initiation activities.
  • The provider must document any failure to complete the pre-initiation activities for routine referrals by the due date, including:
    • the reason for the delay, which must be beyond the provider's control;
    • either the date the provider anticipates it will complete the pre-initiation activities or specific reasons why the provider cannot anticipate a completion date; and
    • a description of the provider's ongoing efforts to complete pre-initiation activities.
  • The provider must notify the case worker of any failure to complete the pre-initiation activities for expedited referrals before the negotiated date for completion of pre-initiation activities. The case worker may refer the individual to another provider.

 

4655 Initial Service Delivery Plan Changes

Revision 17-1; Effective March 15, 2017

The provider must notify the case worker of a variance in the service delivery plan when the initial service delivery plan developed by the provider:

  • has more hours than authorized on the authorization for community care services form; or
  • has no personal care services, except for Family Care services.

If the provider does not agree with the service plan on Form 2101, Authorization for Community Care Services, after completing pre-initiation activities, the provider must send a notice to the case worker explaining why changes are needed in the initial service plan.

Upon receipt of the written notification, the case worker must contact the individual within two business days to review the service plan and resolve the reported request for a change in tasks or hours. If the individual consents to the initial service plan developed by the case worker, the case worker sends the provider Form 2067, Case Information, advising that the individual is in agreement with the developed service plan. If the individual states that a change is needed, review and update Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, and include the changes on Form 2101 to the provider. Services must be authorized within five days of receipt of the practitioner's statement. If a notification is received after services are authorized, process as an interim change. See Section 4673, Interim Service Plan Changes.

If the individual refuses all personal care tasks on the service plan, advise the individual that he will not be eligible for Primary Home Care or Community Attendant Services. Transfer the individual to Family Care or place on the Family Care Interest List. See Section 2720, Interim Changes, for additional guidelines for service plan changes.

 

4660 Service Authorization

Revision 17-1; Effective March 15, 2017

 

4661 Receipt of the Practitioner's Statement of Medical Need

Revision 17-1; Effective March 15, 2017

Before services can be authorized, the provider must submit Form 3052, Practitioner's Statement of Medical Need, to the case worker (for Primary Home Care (PHC)) or to the Texas Health and Human Services Commission (HHSC) nurse (for Community Attendant Services (CAS)). A copy of the form must be retained in the case record.

 

4661.1 Review of the Practitioner's Statement

Revision 17-1; Effective March 15, 2017

Once the practitioner's statement is received from the provider, the case worker (for Primary Home Care (PHC)) or Texas Health and Human Services Commission (HHSC) nurse (for Community Attendant Services (CAS)) will review the practitioner's statement to ensure that everything needed for authorization is in place.

The case worker (for PHC) or the HHSC nurse (for CAS) must ensure that:

  • the practitioner has completed the Statement of Medical Need and certified the individual has a medical need resulting in a functional limitation;
  • at least one functional limitation related to a diagnosis has been checked;
  • the form has been completed and there is no missing information;
  • the practitioner has signed the form;
  • the practitioner's license number has been entered; and
  • the practitioner's contact information is included.

The practitioner's name and license number must be entered in the Service Authorization System.

The case worker or HHSC nurse will accept the practitioner's certification that the individual has an acceptable medical diagnosis when the "Statement of Medical Need" on Form 3052, Practitioner's Statement of Medical Need, is completed. The practitioner must also check at least one functional limitation related to the diagnosis(es) and the case worker or HHSC nurse accepts that the practitioner has checked an appropriate functional limitation.

Persons with only a diagnosis(es) of mental illness and/or intellectual disability (ID)/intellectual and developmental disability (IDD) are not considered to have established medical need based solely on those diagnoses. However, they may establish medical need through a related diagnosis that results in a functional limitation.

In this situation, the practitioner will not sign the "Statement of Medical Need" on Form 3052 and the provider will notify the case worker that a signed Form 3052 will not be sent. When the case worker does the initial assessment and the applicant/family is stating that the only diagnosis is mental illness or ID/IDD, the case worker may consult with the HHSC nurse before making the referral for PHC or CAS. If it is clear at the time of the initial assessment there is no other medical diagnosis or if a signed Form 3052 cannot be obtained, the applicant may be placed on the Family Care interest list, or if funds are available and there is no interest list, may be assessed for Family Care services.

 

4661.2 Required Corrections

Revision 18-1; Effective June 15, 2018

Some problems related to the practitioner's statement will require correction. The case worker or Texas Health and Human Services Commission (HHSC) nurse must review the practitioner's statement within two business days after receipt to determine if all information is correct or if it will require correction. If correction is required, action must be taken that same day. Depending on the type of error, HHSC will either return the practitioner's statement to the provider for correction or obtain the information via a telephone call, requesting faxed confirmation when necessary.

Obtain the information via a telephone call when:

  • functional limitation is not checked;
  • practitioner's signature is not on Form 3052, Practitioner's Statement of Medical Need;
  • provider/financial management services agency (FSMA) did not complete Part II that the practitioner who signed the order is not excluded from participation in Medicare or Medicaid;
  • Form 3052 does not include the credential of the medical practitioner who signed the form (MD for Doctor of Medicine, APN for Advanced Practice Nurse, DO for Doctor of Osteopathic Medicine, PA for Physician Assistant);
  • Form 3052 does not include the license number or the individual National Provider Identifier (NPI) number of the practitioner who signed it;
  • the provider must fax an updated copy of Form 3052 to the case worker or HHSC nurse because the practitioner's signature date is missing or illegible; or
  • the provider must fax an updated copy of Form 3052 to the case worker or HHSC nurse when the provider's stamped date is used instead of the practitioner's date on Form 3052, which does not include the provider name, abbreviated name or initials; or
  • the case worker or HHSC nurse requires additional information to authorize services.

The provider is given five business days to complete all corrections. If appropriate, expedited procedures may be used to refer the individual to another provider.

Form 3052 will not need to be corrected for missing medical diagnosis and ICD-10 codes if the functional limitation has been checked.

 

4661.3 Closing Initial Referrals for Delays in Securing a Signed Practitioner’s Statement

Revision 17-1; Effective March 15, 2017

When contacts from the program provider and case worker have proven unsuccessful in obtaining a signed practitioner’s statement, the case worker may close the initial referral for services within 90 calendar days from the date of the initial Form 2101, Authorization for Community Care Services.

In cases in which the individual or provider agency indicates to the case worker that an appointment has been made with an alternative physician for the purpose of obtaining the practitioner’s statement, the case worker shall continue to monitor the initial referral for up to 90 additional days. The case worker closes the referral by sending Form 2065-A, Notification of Community Care Services, to the applicant if the physician’s statement has not been obtained following the second 90-day extension period.

The case worker will place the individual on the Family Care interest list, and must advise Medicaid for the Elderly and People with Disabilities (MEPD) that the applicant was not approved for CAS. In this circumstance, the case worker must send Form H1746-A, MEPD Referral Cover Sheet, stating the applicant has not met the functional eligibility requirements.

 

4662 Authorization of Services

Revision 17-1; Effective March 15, 2017

 

4662.1 Authorization for Routine Referrals

Revision 17-1; Effective March 15, 2017

For Primary Home Care (PHC), within five business days of receipt of the completed practitioner's statement, the case worker must enter the information into the Service Authorization System Online (SASO) and send authorization Form 2101, Authorization for Community Care Services, to the provider. The "Begin Date" (Item 4) on Form 2101 is the same as the "Mail Date" (Item 1). Form 3052, Practitioner's Statement of Medical Need, must be date stamped on the date of receipt. The case worker files Form 3052 in the individual's record. Services cannot begin until the provider receives Form 2101 authorizing services. The provider has seven days to initiate services after receipt of Form 2101. The case worker sends Form 2065-A, Notification of Community Care Services, to the individual within two business days of the "Begin Date" on Form 2101.

For Community Attendant Services (CAS), within five business days of receipt of the completed practitioner's statement and Form 2101, the Texas Health and Human Services Commission (HHSC) nurse must enter the information into SASO and send authorization Form 2101 to the provider and send a copy to the case worker, or notify the case worker by electronic mail. If the region elects to have the regional nurse notify the case worker by email, the nurse must include the individual's name, identification number, type of case action (initial, annual reauthorization, etc.) and date of authorization in the email. The unit supervisor and/or other appointed HHSC staff will also receive the notice. The case worker must go into SASO and print a copy of Form 2101 from SAS and a copy of the email for the case record.

The "Begin Date" (Item 4) on Form 2101 is same as the "Mail Date" (Item 1). Form 3052 must be date stamped on the date of receipt. The HHSC nurse sends Form 3052 by mail, fax or electronic scan to the HHSC case worker for retention in the individual's case record. The case worker must file the form in the case record and retain the form according to established form retention schedules. Services cannot begin until the provider receives Form 2101 authorizing services. The provider has seven days to initiate services after receipt of Form 2101.

The case worker sends Form 2065-A to the individual within two business days of receipt of Form 2101 from the HHSC nurse. Form 2101 must be date stamped when it is received in the case worker's office.

 

4662.2 Authorization for Expedited Referrals

Revision 17-1; Effective March 15, 2017

When the provider orally notifies the case worker that the practitioner's statement has been received, the case worker must ask for the functional limitations, the practitioner's name and license number, and the signature date. The case worker and provider negotiate a begin date for services. The case worker enters the information in the Service Authorization System Online (SASO) and generates Form 2101, Authorization for Community Care Services, within five calendar days, entering the negotiated date as the begin date. In "Comments," the case worker enters the information on the oral notification, including the provider representative and date of negotiation. Form 2101 must be sent to the provider within five calendar days of the negotiation. The case worker sends Form 2065-A, Notification of Community Care Services, to the individual within two business days.

Each region must ensure there is always a case worker available to negotiate a start of care date on expedited referrals.

The provider must send the completed practitioner's statement to the Texas Health and Human Services Commission (HHSC) within seven business days of service initiation. If a completed practitioner's statement is not sent to HHSC within seven business days of service initiation, the provider is not entitled to payment from HHSC until the date HHSC receives the completed practitioner's statement. In this circumstance, the case worker changes the service initiation date in SASO to the date HHSC receives the completed practitioner's statement and sends the provider a corrected Form 2101.

 

4663 Effective Dates

Revision 17-1; Effective March 15, 2017

The case worker (for Primary Home Care) or Texas Health and Human Services Commission nurse (for Community Attendant Services) establishes the beginning date of coverage for initial cases on Form 2101, Authorization for Community Care Services, Item 4, as the date the form is expected to be mailed to the provider. If this date is not feasible, the beginning date of coverage is negotiated according to the individual's needs and the unique circumstances of the case.

See Section 4664, Time-Limited Services, for additional information.

 

4664 Time-Limited Services

Revision 22-1; Effective March 1, 2022

If the practitioner believes the individual may not need services ongoing, they may choose to put an end date on Form 3052, Practitioner's Statement of Medical Need. Since time-limited services are not often requested, there are special procedures for handling the request.

  1. The initial assessment and referral processes remain the same.
  2. When the provider receives Form 3052, indicating a need for time-limited services, the provider sends a copy of the form to the Texas Health and Human Services Commission (HHSC).
  3. The case worker (for Primary Home Care (PHC)) or HHSC nurse (for Community Attendant Services (CAS)) completes the authorization for services and enters an end date on Form 2101, Authorization for Community Care Services. Explain the reason for an end date in the comments section. Example: "Individual needs services because of a broken arm; full recovery expected in three months," or “practitioner has specified time limited services ending on XXXXX.”
  4. The case worker enters a monitor date into the Service Authorization System Online (SASO) scheduler and plans to monitor the individual at least 30 days before the end date on Form 2101.
  5. At the scheduled time, the case worker contacts the individual to see if his needs have been met or if he requests continued PHC or CAS services.
  6. If the individual's needs have been met, the case worker closes the case by sending the individual Form 2065-A, Notification of Community Care Services, with a 12-day prior notice and enters a date and termination code of "14-No Medical Need" on Form 2101. The effective date of termination on Form 2065-A is the same as the end date on Form 2101.
  7. If the individual wishes to continue PHC or CAS services, the case worker must send Form 2065-A at least 12 days prior to, but not more than 30 days prior to, the Form 2101 end date informing the individual that if a new Form 3052 is not received before the end date of Form 2101, services will be terminated. The case worker must complete a new Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, and a new Form 2101. The case worker must also advise the provider that a new Form 3052 is required.
  8. If the practitioner refuses to sign Form 3052, the case worker screens the applicant for Family Care (FC) services. If eligible, the case worker refers the applicant for FC services or places the applicant on the FC interest list.
  9. If the practitioner signs Form 3052, the case is authorized and the individual remains eligible for service. The case worker must send a new Form 2065-A to inform the individual of the new certification.

If an individual on CAS has time-limited benefits, the regional nurse will add the end date. The case worker must never change or delete the end date added by the regional nurse when adding an effective date for a plan change:

For example, an individual is certified January 2 for CAS with time-limited services ending December 31. The regional nurse will add the end date of 12/31/XX. During the authorized period, the individual requests a change in July that will be effective August 1. When working the change, the case worker must not change or delete the date added by the regional nurse to add an effective date for the change. The case worker will document in the comments of Form 2101 the normal information regarding the change, including “Increase in hours effective 08/01/XX.” The case worker will also still include in the comments, along with the change information, that the individual has time-limited benefits ending on 12/31/XX. This will give the provider the information regarding the change, including the effective date of the change, but will leave the end date intact.

Also use this process when an individual’s time-limited benefits end after the annual certification. Using the same dates above, the case worker sees the individual for their annual reassessment on October 5 and processes the case October 10, leaving the end date in the authorization of 12/31/XX. Along with the regular annual reassessment comments, the case worker will add the comment that “the individual has time-limited benefits ending on 12/31/XX.” The case worker will still follow the same procedure in the list above starting with number 4 to set the scheduler 30 days before the end date to monitor the individual’s time limited case.

 

4665 Service Initiation and Delivery

Revision 17-1; Effective March 15, 2017

Refer to 40 Texas Administrative Code §47.61, Service Initiation.

 

4665.1 Delays in Service Initiation

Revision 17-1; Effective March 15, 2017

40 Texas Administrative Code (TAC) §47.61(c), Delay in service initiation. A provider may delay service initiation only for reasons not directly caused by the provider, or reasons beyond the provider's control, such as natural or other disasters. The provider must continue efforts to initiate services and set a date, if possible, for service initiation. The provider must document any failure to initiate services by the applicable due date in subsection (a) of this section, including:

(1) the reason for the delay, which must be beyond the provider's control;
(2) either the date the provider anticipates it will initiate services, or specific reasons why the provider cannot anticipate a service initiation date; and
(3) a description of the provider's ongoing efforts to initiate services.
(d) Documentation of service initiation. The provider must maintain documentation of service initiation in the individual's file.

Evaluate the cause of the delay and take whatever action is necessary to ensure the individual receives services at the earliest possible date.

Example: The provider may state the individual's physician is on vacation but is expected to return by a specific date and a practitioner's statement will be obtained as soon as the physician returns. If the delay will not adversely affect the individual, the case worker may decide to take no further action. If the delay is problematic for the individual, the case worker may discuss with the individual the need to obtain a practitioner's statement from another practitioner. Appropriate action may necessitate making a new referral to a different provider.

Each situation is evaluated on a case-by-case basis. The provider may contact the case worker's supervisor if the case worker has a pattern of transferring individuals to other providers even though they have indicated that it is due to reasons beyond their control. The case worker may also contact the contract manager if the provider frequently submits Form 2067, Case Information, to the case worker about a delay in initiating services.

 

4665.2 Service Delivery Requirements

Revision 17-1; Effective March 15, 2017

The provider agency must ensure:

  • services are delivered according to the service plan described in Texas Administrative Code §47.45  (relating to Pre-Initiation Activities);
  • (all authorized and scheduled services are provided to an individual, except in the case of a service interruption; and
  • an individual does not receive, during a calendar month, more than five times the weekly authorized hours on Form 2101,  Authorization for Community Care Services.

 

4670 Ongoing Case Management

Revision 17-1; Effective March 15, 2017

 

4671 Ongoing Case Worker Responsibilities

Revision 17-1; Effective March 15, 2017

Monitor the individual according to Section 2710, Monitoring Visits and Contacts, to review the continued adequacy of the service plan, the quality of service delivery and the individual's condition.

The case worker:

  • reassesses the individual's functional need within 12 months of the previous functional assessment date on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, (see Section 2663, Reassessment of Functional Need); and
  • reverifies financial eligibility status within 24 months of the previous eligibility date on the Service Authorization System (see Section 2662, Redetermination of Financial Eligibility).

In addition to providing ongoing case management services to the individual, the case worker also reports to, and discusses with, the unit supervisor, the contract manager and the provider any apparent deficiencies noted in the provider's delivery of Primary Home Care or Community Attendant Services.

 

4672 Transferring Individuals from Family Care to Title XIX Personal Attendant Services

Revision 17-1; Effective March 15, 2017

When the case worker transfers an individual from Family Care (FC) to Primary Home Care (PHC) or Community Attendant Services (CAS), send a referral packet to the receiving provider. The provider will begin pre-initiation activities, as well as coordinate the end date for FC and begin date for PHC/CAS, with the case worker or Texas Health and Human Services Commission nurse.

The FC authorization must be closed in the Service Authorization System before the PHC/CAS authorization can be opened. Send the individual Form 2065-A, Notification of Community Care Services, within two business days of authorizing services as notification of the program change and (if applicable) of the change in providers.

 

4673 Interim Service Plan Changes

Revision 17-1; Effective March 15, 2017

The individual may request a change in tasks or hours. See Section 2720, Changes Reported in the Individual's Condition or Status during the Certification Period.

The provider may also notify the case worker of any ongoing change in the individual's condition or circumstances that may require a service plan change or service termination. Any of the following changes in the individual's condition or circumstances may require a change in the service plan. (These are examples only.)

  • Individual's health improves or deteriorates;
  • Individual no longer needs services;
  • Individual is discharged from a hospital;
  • Problems exist with family relationships;
  • Individual is evicted or otherwise loses housing;
  • Individual relocates;
  • Individual is referred for home health services; and/or
  • Changes occur in the individual's household composition.

 

4673.1 Temporary Service Plan Variances

Revision 17-1; Effective March 15, 2017

The provider may temporarily vary the service delivery plan at the individual's request as long as the variance in tasks can be provided within the total approved hours. The case worker will not be advised of the temporary variance unless the circumstance lasts for more than 60 days.

The provider must provide services according to the existing service delivery plan, until the provider receives a new Form 2101, Authorization for Community Care Services, except the provider may temporarily change the service delivery plan if:

  • the individual requests and requires temporary assistance with allowable tasks not identified on the service delivery plan due to a change in circumstances or available supports; and
  • the change in tasks does not increase the total approved hours of service or continue for more than 60 days.

The provider must request and obtain a new Form 2101 when a temporary variance in tasks and/or hours on the service delivery plan is to continue for more than 60 days or would result in more hours of services provided than have been approved.

If the temporary variance lasts for more than 60 days, the provider must notify the case worker and request a new Form 2101 for the change. The case worker must follow normal procedures for responding to reported changes as outlined in Section 2720, Interim Changes. If the provider does not request a new authorization, then the service plan delivery must go back to the original authorization of tasks and hours.

 

4673.2 Ongoing Service Plan Changes

Revision 17-1; Effective March 15, 2017

Refer to 40 Texas Administrative Code §47.67(a), Increase in hours or terminations.

If the case worker receives a request for a change, he must respond to it within 14 calendar days from the date the request is received. Contact the individual and review the individual's service plan to decide whether the change is necessary. If the case worker decides the change is not necessary, document the reasons on Form 2067, Case Information, and send it to the provider. Keep a copy of Form 2067 in the case record.

Depending on the individual's new condition or situation, a new assessment or revision of the service plan (such as the need for more hours or a different priority level) may be necessary. If appropriate, make changes to the service plan on Form 2101, Authorization for Community Care Services, according to Section 2720, Interim Changes. Consult with the supervisor about the requested change, if necessary. If the change in circumstances meets the criteria for Adult Protective Services, refer the individual to that service. See Section 2220, Response to Requests for Service.

For Community Attendant Services interim changes and provider transfers during the service plan year, the case worker can authorize changes without authorization from the HHSC regional nurse. The case worker enters the "Begin Date" on Form 2101 based on the case action (increase or decrease). The effective date on Form 2065-A, Notification of Community Services, must match the "Begin Date" on Form 2101.

 

4673.3 Increase in Hours

Revision 17-1; Effective March 15, 2017

For expedited or routine service plan changes resulting in an increase in hours, set the begin date on the authorization form. Within two business days of the case decision, the case worker sends the:

  • negotiated date of increase as the begin date on Form 2101, Authorization for Community Care Services; or
  • routine date of increase as the begin date on Form 2101, which must be seven days later than the date the form is expected to be mailed. There may be times when unique or extenuating circumstances make it more appropriate to make the increase later than seven days. In these circumstances, the begin date of coverage is negotiated between the case worker and the provider according to the individual's unique needs. The increase should not be delayed solely because the delay is more convenient for the provider.

Send Form 2101 to the provider.

 

4673.4 Immediate Increase in Hours

Revision 17-1; Effective March 15, 2017

Refer to 40 Texas Administrative Code §47.67(c), Immediate increase in hours of service.

Upon notification from the provider that the individual requires an immediate increase in hours, the case worker or the designated case worker immediately contacts the individual to verify the need for the immediate increase. Review the tasks and hours on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, making the necessary

Revisions to the service plan. Contact the provider and negotiate an effective date for the increase. The request for an immediate increase must be responded to within the same day of the request. Within three business days, send a revised Form 2101, Authorization for Community Care Services, documenting the reason for the increase, the additional tasks and/or hours, the effective date and the provider representative contacted to negotiate the effective date. See Section 2721, Service Plan Changes, for additional information.

The following are examples of situations that require immediate response:

  • The individual is experiencing a major illness and has no available caregiver.
  • The individual suddenly loses his caregiver and has no other available caregiver and
    • is totally bedridden or unable to transfer from bed to chair without assistance; or
    • cannot manage toileting tasks without personal assistance; or
    • needs meal preparation or feeding to ensure that he receives daily nourishment.

Each region must ensure there is always a case worker available to negotiate an immediate increase in hours.

 

4673.5 Termination or Reduction of Hours

Revision 17-1; Effective March 15, 2017

Reduce hours or terminate services when the individual:

  • 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 resulting in the need to reduce or terminate services.

Use personal judgment to determine if the individual's long term improvement is expected to last through the current authorization period or beyond before services are reduced or terminated. If the case worker determines the individual's condition has temporarily improved because the individual is performing the task(s) previously done by the attendant, the individual and provider may agree to a temporary variance. To continue to qualify for Title XIX personal attendant services, the individual must need at least one personal care task.

For changes made in conjunction with an annual reassessment of Community Attendant Services cases, the Texas Health and Human Services Commission (HHSC) nurse must authorize the change.

For decreases, the change is effective 12 days from the date in Item 1 on Form 2101, Authorization for Community Care Services, unless waived by the individual. The effective date of decrease on Form 2065-A, Notification of Community Care Services, must match the effective date of decrease entered in Item 4 of Form 2101.

If services are terminated, follow the individual notification procedures in Section 2810, Notice of Ineligibility or Service Reduction. Coordinate the effective date of denial of services with the provider and HHSC nurse (if appropriate) to allow enough time for the individual to appeal.

 

4673.6 Temporary Loss of Eligibility and Reinstatement Procedures

Revision 17-1; Effective March 15, 2017

When an individual loses Medicaid or financial eligibility as determined by Medicaid for the Elderly and People with Disabilities (MEPD), the case worker must check the Texas Integrated Eligibility Redesign System (TIERS) to verify the denial and the reason. The case worker must contact the individual to discuss the situation and, if feasible, assist the individual with reinstatement of eligibility. If eligibility is reinstated without a gap in eligibility dates, no further action is needed. See Section 3441, Loss of Categorical Status or Financial Eligibility, Section 3441.1, Procedures Pending Reinstatement, and Section 3441.2, Reinstatement Procedures After Denial, for case worker procedures.

If the individual's Medicaid or financial eligibility is later reinstated after a gap in eligibility, the individual may not be automatically placed back on Primary Home Care (PHC) or Community Attendant Services (CAS), if the service has been terminated.

If HHSC notifies the provider that services are terminated, all pre-initiation activities, including medical need determination, must be completed before services are reinstated.

If the case worker has sent Form 2101, Authorization for Community Care Services, terminating services, then the case worker must send a referral Form 2101 for PHC or CAS to the provider for pre-initiation activities, including a new Form 3052, Practitioner's Statement of Medical Need. Expedited procedures may be used in this situation, if appropriate. All policies regarding new referrals apply, including those for CAS and the authorization of services by the HHSC regional nurse. If the individual was placed on another service, the transfer between services must be negotiated for end dates and begin dates and the individual must be notified on Form 2065-A, Notification of Community Care Services.

 

4673.7 Implementation of Service Delivery Plan Changes

Revision 17-1; Effective March 15, 2017

The provider must implement the service delivery plan change on the following date, whichever is later:

  • the authorization begin date on Form 2101, Authorization for Community Care Services; or
  • five days after the date the provider receives Form 2101, unless the provider fails to stamp the receipt date on the form, in which case the authorization begin date on the form will be used to determine timeliness.

If a provider does not implement a service delivery plan change on the effective date of the change, the provider must set a new implementation date. The provider must document by the next working day any failure to implement a service delivery plan change on the effective date of the change. The documentation must include:

  • the reason for the failure to timely implement the service delivery plan change; and
  • the new implementation date.

 

4674 Service Interruptions

Revision 17-1; Effective March 15, 2017

A service interruption occurs anytime service delivery is discontinued for 14 days or more. The provider should make every effort to ensure that interruptions in service last less than 14 days, particularly if a break in service would jeopardize the individual's health or safety. When an interruption of services is unavoidable, the provider must document in the individual's file all service interruptions by:

  • the 30th day after the beginning of the service interruption for priority individuals; and
  • the 30th day that exceeds 14 days after the service interruption for non-priority individuals.

The provider is not required to advise the case worker that service interruptions have occurred. If the individual contacts the case worker or if the case worker learns of the interruption during a monitoring contact, the case worker takes the following actions:

  • The case worker contacts the individual to determine if the service interruption is jeopardizing the individual's health and safety or is having an adverse impact on the individual.
  • If there is no adverse impact and the individual is willing to wait for services, the case worker documents this information in the case narrative.
  • If there is an adverse impact, the case worker:
    • contacts the provider to determine the status of resuming services;
    • contacts the individual and discusses the individual's right to change providers if the provider cannot provide a resumption date; and
    • follows procedures in Section 4676, Change of Providers, if the individual elects to change providers.

 

4675 Interdisciplinary Team

Revision 17-1; Effective March 15, 2017

The interdisciplinary team (IDT) is a designated group that includes the following people who meet when the provider identifies the need to discuss service delivery issues or barriers to service delivery:

  • the individual or the individual's representative, or both;
  • a provider representative; and
  • an HHSC representative, who may be the:
    • case worker (or designee);
    • case worker’s supervisor (or designee);
    • contract manager (or designee); or
    • HHSC regional nurse (or designee).

A Texas Health and Human Services Commission representative must attend all IDT meetings requested by the provider.

Additionally, the case worker may choose to conduct an IDT meeting to resolve problems before the individual elects to transfer from one provider to another. If the individual remains dissatisfied or continues to request to change providers, he may do so. The individual must always have the freedom of choice in selecting a provider and should not be required to go through the IDT process for this purpose. See Section 4676, Change of Providers, for additional information.

See Section 4677, Suspension of Services and Interdisciplinary Team Procedures, for a detailed description of the IDT's role in service suspensions.

 

4675.1 Individual Reports of Service Delivery Issues

Revision 17-9; Effective September 15, 2017

An individual has the right to voice grievances or complaints concerning the Texas Health and Human Services Commission (HHSC) staff or purchased services without discrimination or retaliation. The individual has a right to report service delivery issues to the Health and Human Services Office of the Ombudsman at 1-877-787-8999. If the case worker is aware of the issue, the case worker must work to resolve the individual's issues. See policy outlined in Section 2746.1, Reporting Service Delivery Issues, for detailed procedures in handling service delivery issues.

 

4676 Change of Providers

Revision 17-3; Effective May 15, 2017

When the individual plans to change providers, the individual must first contact the case worker who:

  • coordinates the transfer to prevent a gap in coverage; and
  • attempts to resolve any problems the individual may have with the current provider before he processes the transfer.

Within 14 calendar days after notification of a request to transfer providers, the case worker contacts the individual and the provider to determine:

  • the individual's reason for dissatisfaction; and
  • whether the individual's satisfaction can be accomplished without changing providers.

The case worker considers if the dissatisfaction is due to services not being provided according to the service plan, problems with the attendant, problems with the provider, or the individual's failure to comply with the service plan.

The case worker may determine that an interdisciplinary team (IDT) meeting is appropriate to discuss the issues and find a resolution to the service delivery issues. (See Section 4675, Interdisciplinary Team, for additional information.) The case worker may terminate the individual's services if the individual refuses more than three times to comply with service delivery provisions by repeatedly and directly, or knowingly and passively, condoning the behavior of someone in his home.

Within three business days of the IDT decision, the case worker authorizes the transfer if:

  • he determines that the individual's satisfaction cannot be met without the individual changing providers and services do not have to be terminated based on failure to comply with the service plan; or
  • the individual insists on transferring to another provider and the case worker determines that services do not have to be terminated based on failure to comply with the service plan.

Within those three business days, the case worker also:

  • asks the individual or the individual's representative to select a new provider and documents the individual's choice in the case record by:
    • coordinating with both providers the date the current provider will stop providing services and the date the new provider will begin services;
    • updating any pertinent information on Form 2059, Summary of Client's Need for Service;
    • updating Form 2101, Authorization for Community Care Services, for ongoing cases by entering the new nine-digit contract number in Item 2; and
    • documenting in the comments section that the individual is changing providers;
  • sends the new provider the updated Form 2101 and Form 2059; and
  • sends the current provider a copy of the updated Form 2101 that includes the effective date the individual changes to the new provider.

 

4677 Suspension of Services and Interdisciplinary Team Procedures

Revision 17-1; Effective March 15, 2017

A provider must suspend services if:

  • an individual temporarily or permanently leaves the provider agency’s contracted service delivery area during a time when the individual would routinely receive services and the individual does not request the provision of services outside the provider agency’s contracted service delivery area;
  • the provider declines the request of the individual for the provision of services outside of the provider agency’s contracted service delivery area and the individual leaves the service delivery area;
  • the individual moves to a location where services cannot be provided under the PHC Program;
  • the individual dies;
  • the individual is admitted to an institution, which is a:
    • hospital;
    • nursing facility;
    • state supported living center;
    • state hospital;
    • intermediate care facility serving individuals with an intellectual disability or related conditions; or
    • correctional facility.
  • the individual requests that services end;
  • the Health and Human Services Commission denies the individual's Medicaid eligibility (not applicable to Family Care services); or
  • the individual or someone in the individual's home exhibits reckless behavior, which may result in imminent danger to the health and safety of the individual, the attendant, or another person in which case the provider agency must make an immediate referral to:
    • the Texas Department of Family and Protective Services or other appropriate protective services agency;
    • local law enforcement, if appropriate; and
    • the individual's case worker.

The provider agency may suspend services if:

  • the individual or someone in the individual's home engages in discrimination against a provider or HHSC employee in violation of applicable law; or
  • the individual refuses services for more than 30 consecutive days.

The provider agency must notify the case worker of any suspension by the first working day after the provider suspends services. The notice must include:

  • the date of service suspension;
  • the reason(s) for the suspension;
  • the duration of the suspension, if known; and
  • a written explanation of the circumstances surrounding the suspension.

Refer to 40 Texas Administrative Code §47.71(d), Interdisciplinary Team (IDT) meeting, and §47.71(e), Resuming services after suspension.

The provider must suspend services if the individual:

  • is not available to receive services;
  • requests that services end;
  • loses Medicaid coverage; or
  • someone in the individual's home exhibits reckless behavior that may result in imminent danger to the health and safety of the individual, the attendant or another person.

The provider may suspend services if the:

  • individual or someone in the individual's home engages in discrimination against a provider or Texas Health and Human Services Commission (HHSC) employee in violation of applicable law; or
  • individual refuses services for more than 30 consecutive days.

In situations of reckless behavior, discrimination or refusal, the provider must convene an IDT meeting within three business days of the date the provider suspends services or identifies an issue that prevents the provider from carrying out a requirement of the program. The IDT meeting may be conducted by telephone or in person.

The IDT must consist of:

  • the individual or individual's representative, or both;
  • a provider representative; and
  • an HHSC representative, which may be the:
    • case worker (or designee);
    • contract manager (or designee); or
    • HHSC nurse (or designee).

If the provider is unable to convene an IDT meeting with all the members present, the provider convenes with available members and sends documentation of the IDT meeting within five days to the regional director for the HHSC region in which the individual resides. Participation by HHSC staff is mandatory; staff must be aware of the requirements for participation in the IDT meeting. Based on a HHSC review of the IDT documentation, further action by the provider may be required.

During the IDT meeting, the team must:

  • evaluate the issue;
  • identify any solutions to resolve the issue; and
  • make recommendations to the provider.

The case worker takes the appropriate action following the IDT meeting, either terminating services or authorizing resuming services. See Section 2820, Service Suspension by Providers. The provider must implement the recommendations of the IDT in accordance with §47.71(e) of the Texas Administrative Code.

 

4677.1 Individual Temporarily Leaving Service Area

Revision 17-1; Effective March 15, 2017

An individual receiving services may continue to receive services while he is temporarily staying at a location outside of the provider’s contracted service delivery area, but within the state of Texas. This will help prevent a disruption in services and protect an individual’s health and welfare while the individual is traveling or staying at a location other than his location of residence.

When an individual makes a request for services outside of the contracted service delivery area to the provider, the provider may accept or decline this request. If the provider accepts the individual’s request, the provider may provide the allowed service to the individual during a period of no more than 60 consecutive days. The provider is not required to pay for expenses incurred by the provider’s employee who is delivering services outside the contracted service delivery area. Within three working days after the provider begins providing services outside of the contracted service delivery area, the provider is required to send a written notice to the case worker notifying him:

  • the individual is receiving services outside of the provider’s contracted service delivery area;
  • the location where the individual is receiving services;
  • the estimated length of time the individual is expected to be outside the provider’s contracted service delivery area; and
  • contact information for the individual.

The case worker will receive written notification from the provider when the individual has returned to the provider’s contracted service delivery area within three working days after the provider becomes aware of the individual's return.

If the provider declines the individual's request for services outside of the service delivery area, the provider will inform the individual or his primary caregiver, parent, guardian or responsible party, orally or in writing, of the reason(s) for declining the request. The provider’s notice will also indicate that the individual or his primary caregiver, parent, guardian or responsible party may request a meeting with the case worker and the provider to discuss the reasons for declining the request. The provider will also inform the case worker in writing, within three working days after declining the request, that the request was declined and the reason(s) for declining the request.

If the individual requests an interdisciplinary team (IDT) meeting, the case worker must convene an IDT meeting with the provider and the individual or his primary caregiver, parent, guardian or responsible party to discuss delivery of services outside the provider’s contracted service delivery area and possible resolutions. The case worker must document the contacts with the individual and the provider in the case record. If a resolution cannot be reached, the case worker must offer the individual a choice of providers or the Consumer Directed Services (CDS) option for services.

Out of Area Service Limitations

If an individual receives services outside the provider's contracted service delivery area during a period of 60 consecutive days, the individual must return to the contracted service delivery area and receive services in that service delivery area before the provider may agree to another request from the individual for the provision of services outside the provider's contracted service delivery area.

If the individual intends to remain outside the provider's contracted service delivery area for a period of more than 60 consecutive days, the case worker must transfer the individual to a provider selected by the individual that has a contracted service delivery area that includes the area in which the individual is receiving services.

 

4678 Annual Reassessments

Revision 17-1; Effective March 15, 2017

For Primary Home Care (PHC) individuals, the case worker must make a home visit and face-to-face interview to conduct an annual functional reassessment and completion/review of Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, every 24 months.

A home visit is not required for a PHC individual if verification of financial eligibility status is not due at the next reassessment. The case worker retains the ability to make a home visit if individual case circumstances require a home visit be made, as indicated in case examples listed Section 2663.2, Determining When a Home Visit is Necessary for Other Services.

For Community Attendant Services individuals, the case worker must make an annual home visit and face-to-face interview to conduct a functional reassessment. If the need for a change in tasks and/or hours is identified at the annual reassessment, Form 2101, Authorization for Community Care Services, will be sent as follows.

 

4678.1 Primary Home Care Annual Reassessments

Revision 17-1; Effective March 15, 2017

For Primary Home Care cases at reassessment with no changes, the service authorization is open ended and nothing is sent to the provider. If there are changes in the service plan, within five business days of the annual contact, the case worker must send the provider Form 2101, Authorization for Community Care Services, and appropriate forms as noted in Appendix XIII, Content of Referral Packets. See Appendix IX, Notification/Effective Date of Decision, for effective dates.

 

4678.2 Community Attendant Services Annual Reassessments

Revision 21-4; Effective December 1, 2021

Reassess eligibility for Community Attendant Services (CAS) at least once every 12 months. The reassessment must include a functional assessment, a review by the provider, and an authorization determination by the regional nurse. 

Complete the annual reauthorization by the end of the 12th month from the previous authorization. This is either the initial authorization or the last annual reassessment. 

Example: CCSE staff complete the annual functional assessment by Oct. 31 and send the referral Form 2101, Authorization for Community Care Services, to the provider. The regional nurse's last annual reauthorization was on Nov. 20 in the previous year and this year will be due by Nov. 30.

Note: Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, is due by the end of the 12th month from the previous Form 2060. 

CCSE Staff Procedures

Complete a functional assessment early enough for the reauthorization process to be completed within the 12-month time frame. If possible, complete the annual functional reassessment during the fourth 90-day monitoring visit for the year. If the annual reassessment is not completed during the fourth 90-day monitoring visit, then another home visit is required to complete the reassessment. The annual reassessment may be completed by phone if Form 2060 has been completed within the last 60 days due to an interim change.  

Send Form 2101 to the provider within five business days from the home visit and:

  • Indicate "Annual Reassessment" in the comments section on Form 2101.
  • If there are changes in the service plan, enter the appropriate "Begin Date" on Form 2101 Enter the information in the Service Authorization System Online Wizards (SASOW). Send Form 2065-A, Notification of Community Care Services, to advise the recipient of the changes in the service plan.
  • If there are no changes in the service plan, indicate "No Changes" on the Form 2101 and leave the "Begin Date" blank.

For CAS or Primary Home Care services, if a recipient 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.

Regional Nurse Procedures for Annual Reassessments

For ongoing CAS cases, the regional nurse must review and authorize services annually in SASOW. The authorization in SASOW is required with or without any changes in the service plan. The annual reauthorization is due by the end of the 12th month from the last annual authorization.
The provider must send Form 2101 to the regional nurse with a signed statement of the agreement or disagreement with the service plan, within 14 calendar days of receipt of the referral Form 2101 from CCSE staff.

Provider Agreement

If the provider agrees with the service plan, within five business days of receiving Form 2101 from the provider, the regional nurse completes the authorization of CAS as follows:

  • If there are no changes to the service plan, the regional nurse enters the "Begin Date," which is the same as the "Mail Date," and sends the provider and CCSE staff a copy of the authorization Form 2101.
  • If there are changes in the service plan, the regional nurse reviews the plan and authorizes the service based on the "Begin Date" CCSE staff entered. Enter the "Mail Date" and sends the provider a copy of the authorization Form 2101.
  • The regional nurse notifies CCSE staff by either sending a paper copy of Form 2101 or notification of the authorization email.

If the region elects to have the regional nurse notify CCSE staff by email, the nurse must include the recipient's name, identification number, type of case action such as initial or annual reauthorization, and date of authorization in the email. The unit supervisor or other appointed HHSC staff will also receive the notice. CCSE staff must print a copy of the email for the case record and go into the SASO to print a copy of Form 2101 for the case record.

Provider Disagreement

If the provider disagrees with the service plan, within five business days of receiving Form 2101 from the provider, the regional nurse:

  • negotiates with the provider and CCSE staff to arrive at an agreement on the service plan and the effective date of the change. If the negotiation results in a decrease in services, the effective date must allow time to provide the recipient with 12 days advance notice on Form 2065-A from CCSE staff;
  • makes any necessary changes to Form 2101, noting the negotiated change in the comments;
  • completes the authorization in the Authorization Wizard;
  • sends Form 2067, Case Information, notifying the provider and CCSE staff of the outcome of the negotiation; and
  • sends a copy of the authorization Form 2101.

CCSE staff must send another Form 2065-A to the recipient, noting the negotiated service plan change(s) and the new effective date.

Tracking Receipt of Form 2101 from the Provider

CCSE staff are responsible for tracking the receipt of Form 2101 from the provider. If the authorization Form 2101 is not received from the regional nurse within 14 calendar days of the referral Form 2101 being sent to the provider, CCSE staff will check in SASO to see if services have been authorized by the regional nurse. If services have been authorized, CCSE staff print the authorization Form 2101 and file it in the case folder. If services have not been authorized, CCSE staff contact the regional nurse requesting services be authorized.

The regional nurse enters the authorization in SASO within five business days of receipt of the email from CCSE staff or Form 2101 from the provider, whichever is earlier. The regional nurse sends the provider a copy of the authorization Form 2101 and sends a copy or email to CCSE staff advising the authorization has been completed.

Related Policy 

Annual Recertification, 6333.4
Workflow and Time Frames, Appendix IV