Revision 22-2; Effective May 1, 2022
A request to terminate an individual's waiver program services must be submitted by the individual's assigned service coordinator (SC) at the Local Intellectual and Developmental Disability Authority (LIDDA).
By submitting a request to terminate waiver program services, the SC is requesting that HHSC end the individual's waiver program enrollment. By signing and dating Form 3616, Request for Termination of Services Provided by HCS/TxHmL Waiver Provider, all involved parties are indicating an agreement with the termination of services.
Data Entry in the HHSC data system
The program provider must complete the termination entry in the HHSC data system and the SC must review the termination entry in the HHSC data system prior to submitting required documentation for termination of waiver program services.
HHSC prefers to receive required documentation for the termination of waiver program services through the IDD Operations Portal, but it may be faxed to 512-438-4249 or mailed to:
Health and Human Services Commission
Program Eligibility and Support, Mail Code W-551
P.O. Box 149030
Austin, TX 78714-9030
Reasons for Requesting a Termination
There are several valid reasons for requesting that an individual's waiver program services be terminated, and HHSC Program Eligibility and Support (PES) requires specific documentation depending on the reason for the termination. The required documentation for each reason is described below.
Death – When the SC has learned about the death of a waiver program participant, the SC must submit:
- Form 3616, Request for Termination of Services Provided by HCS/TxHmL Waiver Provider (only the program provider and SC are required to sign and date the form), and
- a brief written summary regarding the circumstances surrounding the individual's death.
State Supported Living Center (SSLC) – When an individual is admitted to an SSLC, the individual's program provider must place the individual on suspension of waiver program services (temporary discharge) until after the SSLC makes a recommendation regarding the individual's continued placement at the individual's initial planning meeting, which occurs within 30 days after admission. If the SSLC recommends the individual's continued placement at the SSLC, the only required documentation the SC must submit is a completed Form 3616 (the termination date on the form must be the same date of the initial planning meeting at the SSLC).
Loss of Financial Eligibility (Medicaid) – The following documentation is required:
- a completed Form 3616;
- a written description of the service linkages in place following the individual's termination from the waiver program (if appropriate);
- a copy of the denial letter from the Social Security Administration (SSA) or HHSC (if the denial letter is not available, the SC must document the reason that the letter is unavailable); and
- written documentation of the following:
- a statement that the option of establishing an income or resource trust may allow the individual to have his or her Medicaid eligibility reinstated was explained to the individual or legally authorized representative (LAR) (only applicable if the SSA or HHSC denial was due to excess income or resources);
- the reason that the individual or LAR gave for not wanting to establish an income or resource trust (only applicable if the SSA or HHSC denial was due to excess income or resources);
- a statement of whether or not the individual or LAR intends to request a fair hearing to appeal the SSA or HHSC decision; and
- a signature sheet signed and dated by all involved parties as indication of understanding and agreement of all of the above.
Voluntary Withdrawal – There are several reasons an individual or LAR may choose to voluntarily withdraw from the waiver program. In every instance a completed Form 3616 must be submitted. Additional required documentation is based upon the reason for the voluntary withdraw as explained below:
- If the individual or LAR has selected a different waiver or program, the SC must submit a description of the services available to the individual through the other waiver or program, the reason(s) the individual/LAR stated for choosing the other waiver or program, and how that program will better meet the individual's needs.
- If the individual has moved out of state, the SC must submit written documentation regarding the stability of the move (for example, where, why and with whom the individual has moved).
- If the individual no longer wishes to participate in the waiver program, the SC must submit records documenting all attempts to encourage the individual's participation and the specific reason(s) that the individual or LAR states for no longer wishing to participate.
- If the individual or LAR has decided to reside in a nursing facility setting although the individual is capable of being served in a community setting, the SC must submit documentation regarding the diagnosis and prognosis and the specific reason(s) that the individual or LAR states for choosing a nursing facility setting.
Institutionalization – There are several types of institutionalization. In every instance a completed Form 3616 must be submitted. Additional required documentation is based upon the type of institutional setting as explained below:
- If the individual is admitted to an intermediate care facility for persons with intellectual disability (ICF/ID), the SC must submit documentation regarding the specific reason(s) for the institutionalization (for example, specific behaviors), the date of the institutionalization and the name of ICF/ID.
- If the individual is admitted to a medical hospital, a psychiatric hospital or nursing facility, the SC must submit documentation regarding the diagnosis and prognosis, the reason(s) the individual cannot be served in the community (for example, if the needs of the individual would cause the Individual Plan of Care (IPC) to exceed the cost ceiling, document which service(s) would cause this), the date of admission and the name of the facility.
- If the individual has been incarcerated, the SC must submit documentation regarding the reason(s) for incarceration, the length of the individual's sentence, the type of facility (for example, county, federal, state), the possibility of early release (if appropriate), the original date of incarceration and the name of the facility.
Individual Cannot Be Located – When an individual cannot be located, the SC must submit a completed Form 3616 and documentation of a final attempt to contact the individual. The SC must review the information available in CARE screen C63.The last screen in the C63 sequence shows the mailing address to which HHSC sends the individual's Medicaid card and the SSA sends the individual's Supplemental Security Income check. The SC must mail a letter (by both regular and certified mail) to that address as a final attempt to contact the individual or LAR. The letter must notify the individual or LAR that:
- the individual or LAR has the option of transferring to a different program provider if for any reason the individual or LAR is dissatisfied with the current program provider or Financial Management Services Agency (FMSA);
- if the individual or LAR does not contact the SC within four weeks after the date of the letter, a request for termination of waiver services will be submitted to HHSC;
- if HHSC terminates the individual's waiver enrollment, the individual will no longer be eligible to receive the waiver services, unlimited prescriptions and possibly Medicaid;
- once an individual's Home and Community-based Services (HCS) waiver services have been terminated, the individual or LAR may request that the LIDDA add the individual's name to the end of the HCS interest list; however, due to the length of the HCS interest list, an offer for re-enrollment may not be available for several years (HCS only); and
- if the individual or LAR agrees to voluntarily withdraw from the waiver program, the individual may do so by signing Form 3616, Request for Termination of Services Provided by HCS/TxHmL Waiver Provider, and returning it to the SC in the enclosed self-addressed, stamped envelope (remember to enclose a completed Form 3616 and a self addressed, stamped envelope).
If the individual or LAR does not respond within four weeks from the date of the letter, the SC must submit documentation of all methods used to attempt to locate the individual or LAR and the dates of each attempt (for example, home visits, telephone calls and conversations with family members, neighbors, employers, friends, co-workers, apartment managers) and copies of all letters mailed to the individual/LAR (and a copy of certified return receipt if mailed certified).
Unable to Meet Health/Safety – If an SC believes an individual's health and safety needs cannot be met by the HCS Program, the SC must contact HHSC PES for further instruction.
Role of HHSC PES – Upon receipt of a request for termination of waiver program services, HHSC PES will review all documentation submitted by the SC. If the documentation is not sufficient for termination of the individual's waiver program services, HHSC staff will contact the SC for more information/documentation. If the documentation is sufficient for termination of the individual's waiver program services, PES staff will notify the individual or LAR by certified mail of the decision to terminate waiver program services and the individual's right to request a fair hearing to appeal the decision. The program provider and SC will receive a copy of the notification letter.
Questions regarding this process should be directed to the HHSC PES general email box at: EnrollmentTransferDischargeInfo@hhs.texas.gov or general message line at 512-438-5055.
TxHmL and HCS reference materials are available online at: