Revision 13-2; Effective September 6, 2013
The following words and terms, when used in this manual, have the following meanings unless the context clearly indicates otherwise.
§1915(c) Medicaid Waiver — The provision of the Social Security Act that authorizes the secretary of Health and Human Services to grant waivers of certain Medicaid statutory requirements so that a state may furnish home and community-based services to Medicaid beneficiaries who need a level of institutional care that is provided in a hospital, nursing facility or intermediate care facility for persons with intellectual disability (ICF/ID).
- physical abuse (a physical act by an individual that may cause physical injury to another individual).
- psychological abuse (an act, other than verbal, that may inflict emotional harm, invoke fear or humiliate, intimidate, degrade or demean an individual).
- sexual abuse (an act or attempted act such as rape, incest, sexual molestation, sexual exploitation, sexual harassment or inappropriate or unwanted touching of an individual by another).
- verbal abuse (using words to threaten, coerce, intimidate, degrade, demean, harass or humiliate an individual).
Activities of Daily Living (ADL) — Basic personal everyday activities that include bathing, dressing, transferring (e.g., from bed to chair), toileting, mobility, eating, grooming, positioning and assisting with self-administration of medication.
Community Living Assistance and Support Services (CLASS) — A §1915(c) Medicaid waiver program that provides community-based" id="Community">Community Living Assistance and Support Services (CLASS) — A §1915(c) Medicaid waiver program that provides community-based services and supports to people with developmental disabilities other than intellectual disability as an alternative to residing in an intermediate care facility.
Caregiver — A person who helps care for someone who is ill, has a disability, or has functional limitations and requires assistance. Informal caregivers are relatives, friends or others who provide unpaid care. Paid caregivers provide services in exchange for payment for the services rendered.
Case Manager — An employee of the Case Management Agency (CMA) who serves as the focal point for service planning and delivery. Responsibilities include needs assessment and reassessment, development of the service plan, identifying appropriate community resources, monitoring the appropriateness and quality of services, providing crisis intervention and advocacy, safeguarding individual rights, and keeping records.
- assessing the individual's needs;
- enrolling into the CLASS program;
- developing the Individual's Plan of Care (IPC);
- coordinating the provision of CLASS program services;
- monitoring the effectiveness of the CLASS program services and the individual's progress toward achieving the outcomes identified;
- revising the IPC, as appropriate;
- accessing non-CLASS program services;
- crisis resolution; and
- advocating for the individual's needs.
Consumer Directed Service Agency (CDSA) — The name of the entity that provided financial management services to the individual/LAR who serve as the employer of their service providers. The entity is now called Financial Management Services Agency (FMSA).
Continued Family Service (CFS) Agency — Agency that provides services to an individual age 18 or older who resides with a support family, which allows the individual to reside successfully in a community setting by training the individual to acquire, retain and improve self-help, socialization and daily living skills or assisting the individual with ADL. The individual must be receiving support family services immediately before receiving continued family services. A CFS agency must maintain licensure as a Child-Placing Agency through the Texas Department of Family and Protective Services (DFPS).
Consumer Rights and Services (CRS) — A division within the Department of Aging and Disability Services (DADS) that receives and processes complaints from individuals, family members, providers and the general public about the care, treatment or services provided to an individual.
- denies an individual's request for enrollment into the CLASS program;
- disallows a CLASS program service requested on an IPC that was not authorized on the prior IPC; or
- disallows a portion of the amount or level of a CLASS program service requested on an IPC that was not authorized on the prior IPC.
Department of Aging and Disability Services (DADS) — Texas state agency that provides long-term services and supports to older people and individuals with physical, intellectual and developmental disabilities. DADS also regulates providers of long-term services and supports, and administers the state's guardianship program.
Department of Assistive and Rehabilitative Services (DARS) — Texas state agency that administers programs that ensure Texas is a state where people with disabilities, and children who have developmental delays, enjoy the same opportunities as other Texans to live independent and productive lives.
Department of Family and Protective Services (DFPS) — Texas state agency that protects children, the elderly and people with disabilities from abuse, neglect and exploitation by involving clients, families and communities.
Department of State Health Services (DSHS) — Texas state agency that promotes optimal health for individuals and communities while providing effective health, mental health and substance abuse services to Texans.
Durable Medical Equipment (DME) — Purchased or rented items such as hospital beds, iron lungs, oxygen equipment, seat lift equipment, wheelchairs and other medically necessary equipment prescribed by a health care provider to be used in an individual's home. These items must be reusable. These items may require the Certificate of Medical Necessity form required by Medicare and Medicaid to use certain durable medical equipment prescribed by a health care provider.
Fair Hearing — An administrative procedure that affords individuals the statutory right and opportunity to appeal adverse decisions/actions regarding program eligibility or termination, suspension or reduction of services by DADS.
Habilitation Attendant — A direct service provider who can be an employee of a DSA or a CDS employer who assists an individual to reside successfully in a community setting by training the individual to acquire, retain and improve self-help, socialization and daily living skills or assisting the individual with ADLs.
Health and Human Services Commission (HHSC) — Texas state agency that provides leadership and direction, and fosters the spirit of innovation needed to achieve an efficient and effective health and human services system for Texans. HHSC oversees the operations of the health and human services system, provides administrative oversight of Texas health and human services programs, and provides direct administration of some programs, which is composed of five agencies:
- Health and Human Services Commission (HHSC)
- Department of Aging and Disability Services (DADS)
- Department of State Health Services (DSHS)
- Department of Assistive and Rehabilitative Services (DARS)
- Department of Family and Protective Services (DFPS)
Individual Education Plan (IEP) — An individualized education program developed by the parents and educators for each child with a disability that is developed, reviewed and revised in a meeting in accordance with the Individuals with Disabilities Education Act. The IEP describes the goals the team sets for a child during the school year, as well as any special support needed to help achieve them.
Individual Plan of Care (IPC) — A written plan developed by an individual's service planning team that describes the type and amount of each CLASS program service to be provided to the individual, and services and supports to be provided to the individual through non-CLASS program resources including natural supports, medical services and educational services.
- for an enrollment IPC, the period of time from the effective date of an enrollment IPC, until the first calendar day of the same month of the effective date in the following year; and
- for a renewal IPC, a 12-month period of time starting on the effective date of a renewal IPC.
Individual Program Plan (IPP) — A written plan that describes the goals and objectives to be met by the provision of each CLASS program service on an individual's IPC that are supported by justifications, are measurable and have timelines.
Institutional Services — Medicaid-funded services provided in a nursing facility licensed in accordance with Texas Health and Safety Code, Chapter 242, or in an ICF/ID certified by DADS for a capacity of more than six people.
Intermediate Care Facility for Persons with Intellectual Disability (ICF/ID) — A public or private facility that provides health and habilitation services to individuals with intellectual disabilities or related conditions.
Legally Authorized Representative (LAR) — A person authorized by law to act on behalf of an individual, which may include a parent, guardian or managing conservator of a minor, or the guardian of an adult.
Medicaid — A program administered by the federal Centers for Medicare and Medicaid Services (CMS), and funded jointly by the states and the federal government, that pays for health care to eligible groups of people.
Medicaid Eligible — A person who is financially eligible for Medicaid because the individual receives Supplemental Security Income (SSI) cash benefits or is determined by HHSC to be financially eligible for Medicaid.
Money Follows the Person (MFP) — A policy that allows residents of nursing facilities to enroll into certain Medicaid waiver programs without having to wait on a program interest list upon determination of program eligibility.
Mutually Exclusive — DADS waiver or Community Care for the Aged and Disabled (CCAD) services that an individual may not receive while enrolled in the CLASS program because services may be duplicative in addressing the individual's needs.
- medical care,
- personal hygiene, and
- protection from harm.
- skilled nursing care and related services for residents who require medical or nursing care;
- rehabilitation services for the rehabilitation of injured, disabled or sick people; or
- health-related care and services, on a regular basis, to individuals who, because of their mental or physical condition, require care and services, above the level of room and board, which can be made available to them only through institutional facilities.
Related Condition (RC) — A severe chronic disability attributed to a condition other than mental illness but found to be closely related to intellectual disability. The condition results in impairment of general intellectual functioning or adaptive behavior similar to that of people with intellectual disabilities and requires treatment or services similar to those required for people with intellectual disabilities. It is manifested before the person reaches age 22, is likely to continue indefinitely, and results in substantial functional limitations in at least three of the following areas of major life activity:
- self care,
- understanding and use of language,
- self-direction, and
- capacity for independent living.
- case manager, and
- DSA representative.
An SPT may also include:
- other people as requested by the individual/LAR; and
- a person selected by the DSA, with the approval of the individual or LAR, who is professionally qualified by certification or licensure and has special training and experience in the diagnosis and habilitation of people with the individual's related condition, or directly involved in the delivery of services and supports to the individual.
Support Family Service (SFS) Agency — Agency providing services to an individual under age 18 who resides with a support family that allows the individual to reside successfully in a community setting by supporting the individual to acquire, maintain and improve self-help, socialization and daily living skills or assisting the individual with ADLs. An SFS agency must maintain licensure as a Child-Placing Agency through DFPS.
Transition Assistance Services (TAS) Agency — Agency that provides a one-time service to a Medicaid-eligible resident of a nursing facility located in Texas to assist the resident in moving from the nursing facility into the community.
Texas Health Steps-Comprehensive Care Program — Texas Health Steps is also known as the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) service, which is Medicaid's comprehensive preventive child health service (medical, dental and case management) for individuals from birth through age 20. Texas Health Steps is dedicated to:
- expanding recipient awareness of existing medical, dental and case management services through outreach and informing efforts, and;
- recruiting and retaining a qualified provider pool to assure the availability of comprehensive preventive medical, dental and case management services.
Texas Medicaid & Healthcare Partnership (TMHP) — A coalition of contractors headed by ACS State Healthcare LLC, which administers claims processing for Texas Medicaid and other state health-care programs for the state of Texas, under contract with HHSC.