O-1600, Home and Community-based Services

Revision 18-1; Effective March 1, 2018

This Medicaid waiver provides various community services to people with a diagnosis of mental retardation who would otherwise be inappropriately placed in institutional facilities. Persons may apply and have their eligibility determined while residing in an institution, but must be living in the community to begin receiving waiver services.

See Section O-1100, Application for Waiver Programs.

Waiver Eligibility Component

HHSC is responsible for determining if the person meets the criteria specific to HCS for the waiver eligibility component and will communicate to HHSC that the person has:

  • an ICF/IID-RC VIII level of care (LOC);
  • an approved plan of care or service plan; and
  • a service begin date no later than 30 days from certification.

HHSC will determine that the person is or will be residing in the community.

If HHSC determines that the person is not residing in the community HHSC will take appropriate action and communicate back to necessary parties.

Financial Medicaid Eligibility Component

HHSC is responsible for determining if the person meets the criteria specific to HCS for the financial Medicaid eligibility component and will communicate to any necessary parties that the person has met all eligibility factors. If the person is already eligible for Medicaid through another program under the Texas State Medicaid Plan, the financial Medicaid eligibility component for this waiver has already been met.

When determining financial Medicaid eligibility for HCS, give special consideration to the following:

  • Receipt of a signed and dated application. See Section O-1100, Application for Waiver Programs, and Section B-4000, Date of Application.
  • Age of the person. If the person's age is less than 65 and the person does not receive a Social Security Administration (SSA), SSI or Railroad Retirement (RR) disability benefit, a disability determination by HHSC is required even if the person has received an LOC under the waiver eligibility component criteria.
  • Post-DRA transfer of assets. The person is ineligible until the transfer does not appear during the look-back period. See Chapter I, Transfer of Assets, for calculation of penalty period.
  • Post-DRA substantial home equity. A person with a home whose equity interest in the home exceeds the established limit is not eligible for waiver services unless the person's spouse, child or disabled adult child is also living in the home.
  • Support and maintenance and deeming. Even if the person receives support and maintenance, do not develop this as income. If the person is living with parents or spouse, do not deem.
  • Income limit. Use the special income limit – 300% cap limit. See Appendix XXXI, Budget Reference Chart.
  • Co-payment calculation. Always determine the co-payment calculation for HCS for initial applications. Reference the appropriate worksheet from Appendix XXII, Home and Community-Based Services Waiver Program Co-Payment Worksheets, to check the calculations made in TIERS.
  • Spousal impoverishment resources. If married, consider spousal impoverishment for a waiver. See Chapter J, Spousal Impoverishment.
  • Spousal co-payment. See the appropriate worksheet from Appendix XXII to determine the spousal diversion or the dependent allowance.

Multiple Program Processing

If there is a delay in certifying the waiver services because the waiver eligibility component criteria has not been met or there is no available waiver slot, certify the person for other benefits for which the person may be entitled, such as QMB or SLMB, as soon as eligibility can be determined. If the application is due, delay of certification procedures should be used for the ME – Waiver EDG.

This allows the application to remain open for an additional 90 days.

HHSC notifies MEPD by completing and sending Form H1746-A, MEPD Referral Cover Sheet, to the Midland Data Processing Center. MEPD continues to notify HHSC of eligibility status using the MEPD communication tool (https://apps-hhsconnection.txhhsc.txnet.state.tx.us/me-to-dads/).

When all pending waiver eligibility component criteria have been met and there is an available slot, complete a disposition of the ME – Waiver EDG.

If the delay of certification period is expiring, and the waiver eligibility component criteria have not been met or there is still no available slot, proceed with denial of the ME – Waiver EDG. The MEPD specialist informs HHSC of the denial using the MEPD communication tool.

When a person is already a Medicaid recipient, review the case.

See Section O-1100, Application for Waiver Programs, before processing a program transfer directly to the HCS program.

Instructions for Processing the Program Transfer

  • After reviewing the case, if the person is eligible for a waiver and is already an institutional (ME – Non-State Group Home, ME – State Hospital or ME – Nursing Facility) or CAS (ME – Community Attendant) MEPD Medicaid recipient, process a program transfer directly to ME – Waivers. The QMB or SLMB coverage must be continued if the person continues to meet the QMB/SLMB eligibility criteria.
  • When a program transfer for a noninstitutional MEPD Medicaid recipient is processed to ME – Waivers and waiver services have been authorized/received before the program transfer effective date, request a force change to ensure retroactive coverage of the waiver services.
  • See Appendix XLV, Program Transfer with Form H1200 Guide, to determine if a Form H1200 is needed. Verify resources and income including transfer of resources and substantial home equity. If there is a community spouse, verify all income and resources and treat according to spousal policy.

Notices

When the financial Medicaid eligibility component is determined, follow established procedures from the HHSC Office of Eligibility Services (OES) on notifications.

If the applicant does not meet the financial Medicaid eligibility component criteria for HCS Medicaid, send the appropriate denial notice to the person with a copy to the proper designee. Continue to send notices regarding QMB, SLMB, MQMB and MSLMB eligibility to the person with a copy to the proper designee.

The financial Medicaid eligibility component redeterminations follow an annual schedule. When a recipient fails to return the review form, the recipient may be denied.

Co-Payment

To comply with the federally approved waiver, co-payment must be calculated for any person in a waiver whose eligibility is determined under the special income limit. See Appendix XXII, Home and Community-Based Services Waiver Program Co-Payment Worksheets, for the sequence in which deductions are allowed. Allow deductions indicated on the appropriate co-payment worksheet. For HCS, the co-payment usually will be $0 unless a QIT is involved. Notify the HHSC designee of the co-payment amount using the MEPD communication tool, even if the co-payment is $0 at initial application. For redeterminations and reported changes, notify HHSC only if the co-payment amount changes.

Medical Effective Date (MED)

An MED can be established when all the criteria are met for both the:

  • waiver eligibility component; and
  • financial eligibility component.

See Section R-1200, Medical Effective Date. For waiver eligibility, the medical effective date is one of the following:

  • The first day of the month of entry to a nursing facility, ICF/IID or state supported living center if the applicant filed a Medicaid application during that month, then requested a program transfer before being certified, and met all eligibility criteria.
  • The first day of the month if the applicant met all waiver eligibility component and financial Medicaid eligibility component criteria. See Section O-1100, Application for Waiver Programs.
  • The day after the effective date of SSI denial for persons transferred from SSI assistance to a MEPD program (excluding any Medicare Savings Program).

Notes:

  • Remember to consider eligibility for QMB and SLMB, including prior coverage for SLMB, and prior coverage if the person was in a nursing facility, ICF/IID or state supported living center before the waiver.
  • A person can also be eligible under Category 2 for HCS through Texas Works Medicaid or through the foster care program. Assist in verifying Medicaid eligibility coverage and take no further action on these cases.
  • A Medicaid recipient is still eligible for Texas Health Steps until age 21.
  • Restitution and reconciliation policy does not apply.