Chapter 5: Service Delivery Process

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Revision 19-1, Effective March 1, 2019

 

5.1 Initial Contact

An individual’s or referral organization’s first contact with a service provider is a critical point in the independent living services (ILS) process. It is a time for an information exchange that will provide the individual or referral organization with information regarding the individual’s independence needs and form impressions related to whether the ILS Program may meet those needs. The service provider must gather the referred individual’s demographics required to be entered into the Independent Living Services Data Reporting System. If the referral organization is unable to provide all demographic information, the service provider will contact the individual to obtain necessary data to complete the initial contact.

The initial contact date is the first request for assistance that requires an application, eligibility determination, and funding under this ILS Program contract. The initial contact is date sensitive and is entered into the Independent Living Services Data Reporting System.

(Note: A consumer may have previously contacted the service provider and received any or all of the independent living core services funded, as addressed in 40 TAC. Part 2, §§104.201 and 106.1001 Allocation of Funds.)

 

5.2 Application for Services

When an individual has made a request for services included in the program scope of services covered by the contract, an application should be processed within 30 days of initial contact. Any circumstances delaying the completion of an application should be noted in the case file.

Applications may not be completed by telephone or other remote methods, such as, Skype, FaceTime, GoToMeeting, and so on. The meeting should be in an accessible location of the individual’s choosing that may include the individual’s home, confidential space in a community setting, or the service provider’s facility. If an individual is unable to apply in person at an office location, a home visit to complete the application must be conducted.

The service provider must develop and maintain an application process to provide, in accessible format, information related to:

  • consumer rights;
  • rights to complain or appeal a process decision (see 4.1.1 and 4.1.2);
  • disposition of confidential information;
  • permission to collect and/or release information;
  • assignment of a representative for minors or when the consumer chooses to be represented;
  • the consumer participation system and need for financial records, if determined eligible to receive services;
  • voter registration information (see 8.5); and
  • additional services for veterans (see 8.9).

The service provider must develop a process for gathering information from the consumer related to:

  • the consumer’s perspective, abilities, resources, limitations, and other issues that impact his or her ability to function in the home, family, and/or community;
  • goals for independence;
  • services considered to address independence goals;
  • existing service provider relationships; and
  • other considerations that will support the eligibility decision.

Information gathered will be documented in the consumer case file for use in eligibility determination.

 

5.3 Eligibility

To be eligible for independent living services, an individual must:

Under Texas Government Code §531.02002 and §531.02014 and Texas Labor Code §351.002, consumers who are determined to be eligible for independent living services on or before August 31, 2016, remain eligible on September 1, 2016, and are considered grandfathered under the former Department of Assistive and Rehabilitative Services Independent Living Program and do not need to reapply for independent living services to the respective receiving agency on September 1, 2016.

Eligibility requirements are applied without regard to a person's age, color, creed, gender, national origin, race, religion, income or length of time present in Texas.

Eligibility is determined by the service provider, based on the documented diagnosis of a licensed practitioner, such as an MD, DO, Nurse Practitioner or Advanced Practice Nurse, and information gathered from the consumer, to define his or her ability to benefit from services and reach independent living goals. All source records gathered to document eligibility should be maintained as part of the consumer case file. Applicants and consumers are not required to participate in the cost of diagnostic assessments and evaluations.

The service provider must document the eligibility decision, including the records of diagnosis from a licensed practitioner, in the consumer case file. Once a consumer is determined to be eligible for services, the service provider:

  1. notifies the consumer of the eligibility decision and the need to gather financial information from the consumer to include the most recent federal tax return or documents to assess and confirm household size, gross income and allowable expenses;
  2. verifies the benefits of all consumers who may be covered for independent living services by comparable services or benefits, as provided under the Independent Living Services Standards, and maintains all related documentation;
  3. assesses the consumer’s ability to pay according to the federal poverty limit guidelines; and
  4. notifies the consumer, or the consumer’s representative, in writing for planning purposes about the assessment of ability to pay and the anticipated percentage to be applied as fee for service.

(Note: Refer to 5.6.3 Consumer Participation in Cost of Purchased Services)

 

5.3.1 Ineligibility

If a service provider determines that an individual is not eligible based on the eligibility criteria in 5.3 Eligibility, the service provider documents the determination of ineligibility and provides HHSC with a copy that is signed and dated by the service provider’s executive director or designee. This ineligibility determination should be filed in the consumer case file along with any supporting documentation.

The service provider may determine an individual to be ineligible for independent living services only after consultation with the individual or after providing a clear opportunity for consultation. See 5.7: Termination of Services.

 

5.4 Pre-Planning Assessment

Assessments and related evaluations required for planning services and IL plan completion may be purchased after eligibility is determined and before the independent living plan’s signed date or waiver date. Consumers are not required to participate in the cost of diagnostic assessments and evaluations.

 

5.5 Assessments for Individuals Who Are Blind

The needs assessment will be conducted in the home (assessments may not be conducted by phone).

The assessment must address the following areas:

  • Daily living skills, such as a consumer’s ability to prepare meals, work safely in the kitchen, measure, pour, eat, perform household chores, sew, do craft work, and provide dependent care (such as helping a spouse or other family member dress or groom).
  • Communication skills, such as a consumer’s ability to read printed material, write, use a calendar, tell time, identify money, manage finances, organize, label, use braille, use a computer, understand technology, and use low vision aids.
  • Ability to manage secondary disabilities, such as hearing loss, diabetes, or other health conditions (for example, whether the consumer needs a deafblind or hearing evaluation, diabetes education, or help managing medication).
  • Ability to travel and transport, such as a consumer’s ability to be mobile in and around the home, detect home deliveries, maintain balance while walking, use public transportation, and travel outside the home (for example, whether the consumer wants to attend orientation and mobility training and, if so, what the consumer’s goals are for travel and mobility).
  • Support systems, such as the consumer’s natural support system, community resources, and needed referrals.
  • Quality of life, such as the consumer’s leisure, volunteer, or recreational activities (for example, whether the consumer wants to be more active and what training would improve the consumer’s quality of life).
  • Adjustment to blindness, such as the consumer’s ability to cope with vision loss, the consumer’s readiness to participate in services, and whether the consumer self-advocates and uses adaptive techniques.
  • Future independence, such as whether the consumer is at risk of going to a more dependent living environment if the consumer does not receive services.

 

5.6 Development of the Independent Living Plan or Waived Independent Living Plan

After determining eligibility, the next step in the independent living services process is to develop the independent living plan (ILP) or waived ILP.

The service provider uses all available information to counsel the consumer about the service options available to help the consumer:

  • identify independent living goals;
  • complete the consumer cost participation requirements; and
  • develop the ILP or waived ILP.

The service provider must fully disclose information available to explore options for services that may meet the consumer’s need in the most cost effective way, minimizing expenditures for the consumer and the program.

The service provider must ensure that the consumer uses comparable services or benefits when developing the independent living plan. Comparable services or benefits include the services and benefits that are provided or paid for, in whole or part, by other federal, state, or local public programs; by health insurance, third-party payers, or other private sources; or by the employee benefits that are available to the consumer and are commensurate in quality and nature to the services that the consumer would otherwise receive from the service provider.

 

5.6.1 Identifying the Independent Living Goals

Suitable independent living goals relate directly to addressing the consumer's functional needs and what the consumer wants to achieve in order to access his or her home, family, and/or community.

Independent living goals are significant life achievements that:

  • enable the consumer to become more, or to remain, independent in the home, family, or community; and
  • are made possible through independent living services.

A consumer may have more than one goal listed on the independent living plan.

Independent living goals may be related to:

  • communication;
  • community-based living;
  • community and social participation;
  • education needed for independent living;
  • information access and technology;
  • mobility and transportation;
  • personal resource management;
  • relocation from a nursing home or other institution;
  • self-advocacy and self-empowerment;
  • self-care; and
  • other areas leading to independent living.

 

5.6.2 Initiating an Independent Living Plan or Waived Independent Living Plan

A consumer's independent living plan or waived independent living plan is initiated after the consumer’s eligibility is documented, according to 5.3 Eligibility. The plan explains the goals or objectives established and the services necessary to meet those goals. These services may include a comparable service that is being arranged for the consumer or a service being provided by staff or purchased for the consumer. It indicates the anticipated duration of the service plan and the duration of each component service.

An IL Plan amendment is required when any changes to the original Independent Living Plan or Waived Independent Living Plan are completed with the consumer. The service provider develops written policies to address IL Plan amendments.

The independent living plan and any amendment are developed by the service provider and the consumer or the consumer’s representative. If the consumer signs a waiver, a waived independent living plan is developed by the service provider.

A copy of the independent living plan and any amendment is provided in an accessible format to the consumer or the consumer’s representative and documented in the consumer’s case file. The waived independent living plan is also documented in the consumer’s case file.

 

The service provider administers the consumer participation system in accordance with the independent living services rules, the Independent Living Services Standards, and the contract requirements. The service provider gathers financial information about the consumer to determine the consumer’s participation.

In summary, the service provider determines the consumer's requirement and ability to participate by:

  1. collecting financial information;
  2. calculating the consumer’s household size and adjusted gross income;
  3. assessing the consumer participation fee according to the published scale;
  4. processing the consumer participation agreement with the consumer; and
  5. documenting the agreement in the consumer case file.

The service provider provides independent living core services, and any necessary assessments for the purpose of determining eligibility, and evaluations for determination of appropriate independent living service provision as defined in Chapter 3: Scope of Independent Living Services, 3.1 Scope of Services, at no cost to the consumer.

Purchased independent living services defined in Chapter 3: Scope of Independent Living Services, 3.1 Scope of Services are subject to consumer participation and comparable benefits requirements of the Independent Living Services Standards.

 

5.6.3.1 Collecting Financial Information

When the consumer has been determined eligible for services, the service provider reviews information related to the consumer’s ability to pay.

The service provider gathers financial information about the consumer to determine the consumer’s adjusted gross income and the percentage of the federal poverty level for that income. For planning purposes, the consumer is notified of his or her expected percentage fee for services after the eligibility notification. This allows the consumer to consider his or her fee before agreeing to a plan of services and the opportunity to request a re-review and provide information regarding any exceptional circumstances or further documentation to assess the consumer’s ability to pay.

The request for documented proof of income includes:

  • a federal tax return, including the addition of the parent’s federal tax return for an eligible minor; or
  • benefits award letters, receipts, bank statements, retirement account and any other available financial record to demonstrate income, allowable expenses, and household size.

 

5.6.3.2 Calculating the Consumer’s Household Size and Adjusted Gross Income

Based on financial records provided by the consumer, the household size equals:

  • any person living inside or outside of the home who is eligible to be claimed as a dependent of the consumer on the consumer’s federal income tax return; or
  • if the consumer is a minor, any other person living inside or outside of the home who is eligible to be claimed as a dependent of the consumer’s parent or guardian on the parent or guardian’s federal income tax return.

The consumer’s annual gross income:

  • equals the total annual gross income received by the household; and
  • includes all income classified as taxable income by the Internal Revenue Service before federally allowable deductions are applied.

The consumer’s allowable deductions are limited to the consumer’s expenses in the following categories:

  • Attendant care;
  • Rent or home mortgage payments;
  • Court-ordered child support payments made by the consumer for financially dependent children who were not included in the calculation of household size;
  • Medical or dental expenses for treatment primarily intended to alleviate or prevent a physical or mental illness or manage a disability, with the expenses limited to the cost of:
    • diagnosis, cure, alleviation, treatment, or prevention of disease;
    • treatment of any affected body part or function;
    • medical services legally delivered by physicians, surgeons, dentists, and other medical practitioners;
    • medications, medical supplies, and diagnostic devices;
    • medical and dental health care insurance premiums;
    • transportation to receive medical or dental care; and
    • medical or dental debt that the family is paying on an established payment plan.

The service provider calculates the allowable deductions using the actual amounts the consumer paid during the previous 12-month period, according to financial records provided by the consumer.

The consumer provides the most recent tax return available as proof of annual gross income and allowable deductions. If the consumer has no tax return, the consumer provides bank statements, medical records, receipts, proof of benefits awards, and other documentation to demonstrate annual gross income and allowable deductions.

If the consumer does not provide documentation supporting the household's allowable deductions, the service provider determines the consumer’s fee for service based on the consumer’s documented annual gross income with no allowable deductions.

Once the service provider calculates household size and adjusted gross income, the consumer’s financial situation is assessed to determine the percentage of federal poverty guidelines. The consumer’s fee, listed on the HHSC fee schedule is then based on the corresponding percent of cost to be paid.

Factors that affect the consumer’s fee for service, as described above, are:

  • household size;
  • annual gross income; and
  • allowable deductions.

The consumer’s fee for service is equal to the amount on the HHSC sliding fee scale according to the household's annual adjusted income (that is, the annual gross income minus the allowable deductions).

The service provider uses the most current sliding fee scale and instructions published by HHSC to determine the consumer’s fee for service.

As the independent living plan or waived independent living plan is developed, the service provider and consumer discuss cost of services so that the consumer is aware of the fee that will be due for agreed upon services and, if necessary, request a re-review and provide information regarding any exceptional circumstances.

The service provider charges the consumer a fee for each purchased service provided, according to the consumer’s percentage of the federal poverty level.

 

5.6.3.3.1 Fee Schedule Amount

The service provider is required to use the HHSC fee schedule and instructions to calculate the consumer’s fee for service.

After the independent living plan or the waiver is signed and completed and the service provider is proceeding with the purchase of the good or service, the service provider charges and collects the consumer’s fee for each purchased service provided, according to the consumer participation agreement.

The procedures, fee schedule, and instructions that HHSC uses to calculate a consumer’s fee for service is available from HHSC, between 8:00 a.m. and 5:00 p.m. on business days. The fee schedule is also available on the HHSC Independent Living Services Program website and provided to the consumer.

 

5.6.3.3.2 Insurance Payments

If the consumer has medical and dental insurance that covers an independent living service received by the consumer and the agreement for in-network services made between the insurance company and the service provider or service provider’s subcontractor requires that the service provider or subcontractor accept as payment in full the deductible, copayment, or coinsurance and insurance reimbursement, then the consumer’s fee for service is either the deductible, copayment, or coinsurance, or the amount calculated by the HHSC fee schedule, whichever is less.

The consumer pays the premiums for medical and dental insurance. Neither HHSC nor the service provider pays the premiums.

The premiums for medical and dental insurance do not count toward meeting the consumer’s fee for service.

The service provider may not need to spend independent living service funds to help the consumer achieve his or her independent living goals. Before providing independent living services to a consumer, the service provider explores any possible comparable services or benefits and whether those services and benefits are available to the consumer. The service provider records these services on the independent living plan or waived independent living plan as coordinated services.

All comparable benefits must be exhausted before funds are used for services covered under this contract.

 

5.6.3.4 Processing the Consumer Participation Agreement with the Consumer

The consumer or consumer’s representative signs a consumer participation agreement that indicates the household adjusted gross income level and corresponding percentage fee for services. Signing the agreement acknowledges the amount of the consumer’s fee for services and provides written agreement that:

  • the information provided by the consumer or the consumer’s representative about the consumer’s household size, annual gross income, allowable deductions, and comparable services or benefits is true and accurate; or
  • the consumer or the consumer’s representative chooses not to provide information about the consumer’s household size, annual gross income, allowable deductions, and comparable services or benefits.

The service provider does not initiate or authorize independent living services subject to Chapter 3: Scope of Independent Living Services until the consumer or the consumer’s representative signs the consumer’s participation agreement.

If the consumer chooses not to provide information on the consumer’s household size, annual gross income, allowable deductions, and comparable services or benefits, the consumer agrees to pay the entire cost of services.

As soon as possible the consumer reports to the service provider all changes to household size, annual gross income, allowable deductions, and comparable services or benefits and signs a new consumer’s participation agreement.

When the consumer signs a new participation agreement, the new amount of the consumer’s fee for service takes effect the beginning of the following month. The new amount is not retroactive.

The service provider must develop a process to reconsider and adjust the consumer’s fee for service based circumstances that are both extraordinary and documented. This may include assessing the consumer's ability to pay the consumer’s fee for service.

Only the service provider’s executive director or designee has authority to reconsider and adjust a consumer’s fee for service.

Extraordinary circumstances include:

  • an increase or decrease in income;
  • unexpected medical expenses;
  • unanticipated disability related expenses;
  • a change in family size;
  • catastrophic loss, such as a fire, flood, or tornado;
  • short-term financial hardship, such as a major repair to the consumer’s home or personally owned vehicle; or
  • other extenuating circumstances for which the consumer makes a request and provides supporting documentation.

The consumer’s calculated fee for service remains in effect during the reconsideration and adjustment process.

The service provider:

The service provider does not use program income received from the consumer participation system to supplant any other fund sources.

HHSC does not pay any portion of the consumer’s fee for service.

The consumer’s participation agreement and all financial information collected by the service provider are subject to any data use agreement between HHSC and the service provider, a subpoena, and monitoring.

This documentation must be provided to HHSC in manner requested (hard copy, scanned copied transmitted by mail or electronically or during on-site visits).

 

5.6.3.5 Documenting the Agreement in the Consumer Service Record

A consumer case file is maintained for all applicants and eligible consumers receiving independent living services. All entries to the Independent Living Services Data Reporting System made by the service provider will be considered a part of the consumer case file.

Each consumer case file must minimally meet the requirements of 34 Code of Federal Regulations (CFR), Subtitle B, Chapter III, Part 364, §364.53, and provide documentation concerning:

  • intake information, including prescribed consumer demographics and contact information;
  • application processing to include any and all forms indicating consumer rights notices, permission to collect and release personal information, representative signatures, legal status verification documents, and so on;
  • eligibility or ineligibility determination, including a record provided by a licensed practitioner of diagnosis of a significant disability;
  • services requested;
  • an independent living plan or a signed waiver declining participation in plan development;
  • the consumer’s goals for independence and anticipated methods and services to achieve the goals;
  • services coordinated, arranged, and provided;
  • independent living goals or objectives established with the consumer and achieved by the consumer; and
  • summary case management log notes.

The consumer case file may be in written or electronic form; however, the independent living plan or waiver must have an original signature.

All paper documents received, such as medical records, assessment, quotes or legacy agency files, must be kept in their original format in a paper case file.

The service provider must meet in person with the consumer to process an application for services. The meeting should be in an accessible location of the consumer’s choosing that may include the consumer’s home, confidential space in a community setting, or the service provider’s facility, if the consumer agrees.

 

5.6.4 Completing the Independent Living Plan or Waived Independent Living Plan

Unless the consumer who will receive independent living services under the Independent Living Services Standards signs a waiver in accordance with the requirements of this section, the service provider works with the consumer to develop and periodically review an independent living plan in accordance with this section.

If the consumer knowingly and voluntarily signs a waiver stating that the consumer’s participation in developing an independent living plan is unnecessary, the service provider develops a waived independent living plan.

The service provider provides each independent living service in accordance with the independent living plan or waived independent living plan.

 

5.6.5 Reviewing Annually the Independent Living Plan or Waived Independent Living Plan

At least annually, the service provider must review and update accordingly the consumers plan for services, including:

  • the consumer’s goals;
  • the services delivered and still needed;
  • opportunities for referral or coordination with other programs or resources;
  • the consumer's income, allowable expenses, and any other factors impacting the consumer’s participation agreement; and
  • the review results documented in a summary note in the consumer’s service record.

The consumer reviews the independent living plan and, if necessary, revises it and agrees by signature to its terms.

Any time that the consumer's financial situation changes, the consumer must provide documentation and renegotiate the consumer participation agreement accordingly. All changes and agreements will be captured in the consumer case file.

 

5.6.6 Coordinating With Vocational Rehabilitation, Developmental Disabilities, and Special Education Programs

The review of the independent living plan or waived independent living plan must be coordinated, to the extent possible, with all of the following programs for which the consumer may be eligible and gain benefit:

  • A vocational rehabilitation program
  • A habilitation program, prepared under the Developmental Disabilities Assistance and Bill of Rights Act
  • An education program, prepared under part B of the Individuals With Disabilities Education Act

 

5.6.7 Coordinating with Independent Living Program for Older Individuals Who are Blind (ILS-OIB)

Background

The ILS-OIB program is administered through the Texas Workforce Commission (TWC). OIB staff are located in Workforce Solutions offices across the state and are assigned coverage areas by county. For a list of offices, visit: http://www.twc.state.tx.us/partners/independent-living-services-older-individuals-who-are-blind#contact.

To be eligible for the ILS-OIB program, the individual must be 55 years of age or older and have a significant visual impairment that creates barriers for the individual to live independently.  

Services that the ILS-OIB program provides to individuals may include:

  • Counseling, guidance, and referral services provided by TWC-ILS-OIB staff:
  • Orientation and Mobility Training;
  • Independent Living Services Training;
  • Diabetes Education Training;
  • Low-Vision evaluations; and
  • Adaptive aids, Low-Vision devices.

Individuals may receive goods and services from both programs. To provide coordinated services for mutual consumers, the following activities are expected from both the service provider’s IL staff person and the TWC OIB worker:

  • Monthly or quarterly meetings, as agreed upon, with the OIB worker to discuss mutual referrals.
  • ILS service provider acceptance of referrals for services that are related to non-visual disabilities (e.g., hearing aids, medical equipment).
  • Discussion of ongoing progress with the mutual customer.

Individuals may benefit from one or both programs; therefore, OIB staff and the service provider’s IL staff are required to refer individuals to each respective program and ensure that this referral is correctly captured in the case management system.

 

5.7 Termination of Services

When the goals of an independent living plan are achieved, the service provider stops providing services and closes the case as successful. The service provider reports successful case closures to HHSC.

If a consumer does not meet the goals of the independent living plan and the service provider determines a need to stop providing services, the service provider must close the case as unsuccessful. The service provider reports unsuccessful case closures to HHSC.

For both successful and unsuccessful case closures:

  • the service provider notifies the consumer in writing of the action taken and informs the consumer about the consumer's rights and the means by which the consumer may appeal the action taken or file a complaint;
  • the service provider refers the consumer to other agencies and facilities, if appropriate, including referring the consumer to the state's vocational rehabilitation program, and documents this referral in the consumer case file;
  • if a service provider determines that a consumer is ineligible for independent living services, the service provider reviews the consumer's status again within 12 months of the determination and whenever the service provider determines that the consumer's status has materially changed; and
  • a review of an ineligibility determination need not be conducted if the consumer has refused one, the consumer is no longer present in Texas, or the consumer’s whereabouts are unknown.

 

5.8 Waiting List

Independent living services are provided when funding is available. When funding is not available, the consumer is considered waiting for purchased services.

A consumer is placed on a waiting list by the service provider when the consumer:

  • meets the eligibility requirements explained in 5.3 Eligibility; and
  • has a signed independent living plan or a signed waiver; and
  • is ready for services and there is no funding for the purchased service; therefore, the consumer is considered to be waiting for purchased services until funds are available.

The date the Independent Living Plan is completed with the consumer is used as the date the consumer began waiting for services, if applicable.

Plans for consumers who are waiting for purchased services are reviewed every six months by the service provider to determine whether consumers are still eligible for or interested in services.

Consumers are no longer considered waiting when funding becomes available for the purchased service, the consumer is no longer eligible, or the consumer is no longer interested in the purchased service.

 

5.8.1 If Funds Are Not Readily Available to Purchase the Service

If funds are not readily available to serve the consumer immediately after eligibility determination, do not purchase evaluations such as:

  • therapy evaluations;
  • seating evaluations;
  • residential modification evaluations; or
  • evaluations for other equipment.

Instead, develop the independent living plan using projected costs and estimated service needs.

To estimate the projected needs and costs, use:

  • available medical records;
  • medical evaluations;
  • consumer input; and
  • staff observation.

Within 60 to 90 days before the service provider anticipates having funds available to serve the consumer, purchase or obtain needed evaluations to determine actual costs and specifications.

 

5.9 If a Consumer Is Not Ready to Participate in Services

Sometimes consumers may experience personal circumstances rendering them unable to participate in services. If services are to be delayed for a period of greater than 90 days due to the consumers’ circumstances, the date on which the consumer becomes “not ready” is recorded in the Independent Living Services Data Reporting System with a summary note of circumstances.

Examples of “not ready” may include:

  • an illness or hospitalization;
  • a death in the family requiring an extended pause in services or time out of town; or
  • working through the process of purchasing a vehicle that will not be available for greater than 90 days.

The service provider reviews the “not ready” status with consumers every 60 days to determine whether the consumer is ready to engage in services, should remain inactive temporarily, or needs to terminate services if the consumer is not likely to engage in services.