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Revision 22-3; Effective Dec. 1, 2022
4710 Medically Dependent Children Program Respite Services
Revision 22-3; Effective Dec. 1, 2022
Respite is a service that provides temporary relief from caregiving to the member’s primary caregiver during the times when the primary caregiver would normally provide care. The primary caregiver may be the member’s parent(s), guardian, a family member or spouse, if married. STAR Kids managed care organizations (MCOs) may not require respite providers to obtain a denial or explanation of benefits from a member's primary insurance before seeking reimbursement for respite services.
In-home respite may be delivered by an attendant, LVN, or RN through a home and community support services agency (HCSSA), also called a home health agency, or through the Consumer Directed Services (CDS) option. In-home respite is not limited to the individual’s place of residence. Respite may also be provided in other community settings when the situation does not exceed the limitations documented in Section 4720, Respite Limits. Other community settings could include the park, the respite provider’s home, or a home of the member's relative. Out-of-home respite may be provided in a facility setting, such as a nursing facility or hospital, or in a camp setting.
Respite is intended to provide relief to the primary caregiver. It may only be provided when a member's primary caregiver would normally provide the member's care. Respite may not be delivered while the member is in school or in a school setting. Respite must not be provided at the same time as a duplicative service, such as Community First Choice (CFC) or private duty nursing (PDN). Duplication occurs when Medically Dependent Children Program (MDCP) respite provided by a nurse is rendered at the same time as another in-home nursing service (such as PDN), or when MDCP respite provided by an attendant is rendered at the same time as another attendant care service (such as CFC). Because respite provides relief to the primary caregiver if the caregiver would normally be providing services, respite may be authorized at the same time. For example, a nurse providing PDN is in the member's home for the purpose of such services as suctioning or monitoring vitals and an MDCP respite attendant is in the home at the same time providing CFC to the member to relieve the caregiver of tasks they would normally be responsible for performing. Circumstances which require two personnel for a two-person transfer are not considered a duplication of services. In that case, the private duty nurse and MDCP respite attendant could collaborate to accomplish the transfer. Note: Respite must not be authorized in place of PDN where PDN is most appropriate. Respite is intended to provide relief to the primary caregiver and must only be authorized for that purpose.
STAR Kids MCOs must determine the number of units of respite to authorize for an MDCP member, based on the member or legally authorized representative's preferences, level of care, and the member's approved cost limit. Specialized nursing rates will be paid when a member requires, as determined by a physician, daily skilled nursing to cleanse, dress, and suction a tracheostomy or daily skilled nursing assistance with ventilator or respirator care. The member must be unable to do self-care and require the help of a nurse for the ventilator, respirator or tracheostomy care. MCOs must develop internal processes for respite service schedules, schedule changes, and policies regarding setting aside funds within the individual service plan (ISP). MCOs must develop a process to allow for flexible schedules and allow an MDCP member to "bank" respite hours to use at later point in the ISP year. MCOs must allow members to have flexibility in the use of respite hours, allowing members to carry over respite hours from week to week and month to month. A member cannot carry respite hours over from an expiring ISP to the new ISP.
4711 In-Home Respite
Revision 22-2; Effective September 1, 2022
In-home respite is not limited to the individual’s place of residence. Respite may also be provided in other community settings, which could include the park, the respite provider’s home or a home of the individual’s relative. In-home respite may be provided by a licensed Home and Community Support Services Agency (HCSSA), also called a home health agency, or the provider employed by a member or their legally authorized representative under the Consumer Directed Services (CDS) option.
A member's in-home respite is limited by the amount of the member's cost limit. If the member chooses the CDS option, the member is limited by their available budget. Managed care organizations (MCOs) may have additional policies and procedures regarding reserving capacity in a member's budget. The provision of in-home respite is documented on the individual service plan (ISP).
4712 Attendant with Delegated Tasks
Revision 22-2; Effective September 1, 2022
A delegated task is defined as a task that a physician or registered nurse (RN) delegates in accordance with state law. In general, the Texas Board of Nursing (BON) defines nurse delegation as authorizing an unlicensed person to provide nursing services while retaining accountability for how the unlicensed person performs the task. In brief, the Texas Occupations Code indicates a physician may delegate to a qualified and properly trained person acting under the physician's supervision any medical act that a reasonable and prudent physician would find within the scope of sound medical judgment to delegate. Only an RN may delegate to an attendant under their supervision, per BON rules. A member with a skilled task need may use an attendant with delegated tasks if a physician or RN delegates the skilled task required to meet the member's needs.
If the member does not have a skilled nursing task need for the delivery of respite, they do not have a need for an attendant with delegated tasks. If the member or primary caregiver requests the use of an attendant with delegated tasks, but the nurse service coordinator or the Home and Community Support Services Agency (HCSSA) nurse determines the use of this provider type places the individual's health and welfare at risk, the service coordinator should not authorize an attendant with delegated tasks to deliver respite, unless determined appropriate by the member's physician.
If a member or legally authorized representative (LAR) employs an attendant under the Consumer Directed Services (CDS) option, delegation of certain tasks is not required. Form 1733, Employer and Employee Acknowledgement of Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed Services, outlines what services cannot be delegated, such as specific tasks involved in the implementation of the care plan that require professional nursing judgment or intervention. If the member or their LAR is directing the member's services, they must sign Form 1585, acknowledging responsibility for the training and oversight of an attendant.
4713 Out-of-Home Respite
Revision 22-2; Effective September 1, 2022
Respite may be provided out of the home if indicated in a physician's order or if the member and/or their legally authorized representative prefer. Out-of-home respite providers are:
- special care facilities licensed by the Texas Health and Human Services Commission (HHSC);
- day care facilities licensed by the Texas Department of Family and Protective Services (DFPS);
- hospitals licensed by DSHS and accredited by the Joint Commission on Accreditation of Healthcare Organizations;
- nursing facilities licensed by the Texas Health and Human Services Commission (HHSC);
- camps licensed by DSHS and accredited by the American Camping Association; and
- foster families approved by a DFPS child placing agency.
Facility-based respite is limited to 29 days per the individual service plan period. The 29-day limit applies to the total number of days a member receives respite in a hospital or nursing facility.
4720 Respite Limits
Revision 22-2; Effective September 1, 2022
Respite may only be provided during the time the primary caregiver would usually provide care to the member. Respite may not be provided during the time the primary caregiver is at work, attending school or in job training. All respite settings must be located within the state of Texas.
Title 42 of the Code of Federal Regulations §441.301(b)(1)(ii) requires that home and community based services, like Medically Dependent Children Program (MDCP) services, not be provided in an institution. However, respite may be provided in a hospital or nursing facility (NF) only if the sole reason for the member's admission is respite. For example, if a member is admitted to a hospital for reasons such as illness, surgery or stabilization/treatments, respite must not be authorized concurrently.
The member may request to exceed the 29-day facility-based respite limit. Within five days of the request to exceed the 29-day limit, the managed care organization (MCO) must review the individual’s needs and the primary caregiver’s ability to meet those needs, and determine if the request falls within the respite criteria. The MCO must ensure there is no danger to the member’s health and welfare.
Respite may not be provided in a setting in which identical services are already being provided. This means that a nurse may not provide respite to a member who is receiving out-of-home respite in a camp. Likewise, an attendant may not provide respite to a member receiving out-of-home respite in an NF. Respite may not be delivered by the:
- primary caregiver;
- member's spouse; or
- member's parent, representative, guardian or managing conservator, if the individual is under age 18.
4730 Reserved for Future Use
Revision 17-1; Effective June 1, 2017
4740 Reserved for Future Use
Revision 17-1; Effective June 1, 2017
4750 Flexible Family Support Services
Revision 19-1; Effective June 3, 2019
Flexible family support services (FFSS) are individualized and disability-related services that support a member to participate in age-appropriate activities such as:
- child care;
- independent living; and
- post-secondary education.
FFSS include personal care supports for basic activities of daily living and instrumental activities of daily living, skilled task and delegated skilled task supports. FFSS promote community inclusion in typical child and youth activities through the enhancement of natural supports and systems and through recognition that these supports may vary by child, provider, setting and daily routine. Flexible family support services may be delivered by the Home and Community Support Services Agency (HCSSA) and also may be delivered by attendants or nurses employed through the Consumer Directed Services option. FFSS are documented on the individual service plan. STAR Kids managed care organizations may not require FFSS providers to obtain a denial or explanation of benefits from a member's primary insurance before seeking reimbursement for FFSS.
4751 Flexible Family Support Services in Child Care
Revision 22-2; Effective September 1, 2022
The member's parent or guardian is responsible for basic child care either in or out of the member's home. Flexible family support services (FFSS) support the member's participation in child care when the service provided by the child care does not support the member's disability-related needs. If the member's child care is not able to meet the member's activities of daily living, instrumental activities of daily living, skilled task, non-skilled task or delegated skilled task needs, the service coordinator may authorize FFSS.
To determine the need for FFSS for participation in child care, the service coordinator must discuss the parent's or guardian's plan for obtaining basic child care and whether it will be provided in or out of the member's home or both. The delivery of FFSS does not include basic child care, which is watchful attention or supervision of the member while the primary caregiver is at work, in job training, or at school and not available. These remain responsibilities within the service delivered by the child care provider.
The caregiver's cost for child care does not impact the member's need for FFSS. The service coordinator must determine the number of hours needed to support the member's needs within the Medically Dependent Children Program (MDCP) cost limit. The service coordinator should ask the caregiver about the member's personal and skilled task needs and the time needed to address those needs. The service coordinator should discuss the skill level required to assist the member to address necessary safeguards that ensure the member's health and welfare.
FFSS does not replace personal care services (PCS) provided through Texas Health Steps (THS) or Community First Choice (CFC). FFSS are provided when a member regularly participates in child care in the home or out of the home or participates in a community program or educational service. FFSS are authorized because of a change in the child's condition or when because of the child's condition, the child’s needs cannot be met. In these instances, additional care is required.
4752 Flexible Family Support Services for Independent Living
Revision 22-2; Effective September 1, 2022
A member may indicate a desire for increased independence as they mature. If the member needs assistance with activities of daily living (ADLs), instrumental activities of daily living (IADLs), skilled task, non-skilled task or delegated skilled task, the service coordinator may authorize flexible family support services (FFSS) to help the member with their goals for independent living.
Independent living can be an arrangement that maximizes independence and self-determination and offers opportunities to be as self-sufficient as possible. Although independent living is not a Medically Dependent Children Program (MDCP) service, an independent living arrangement can provide life-skills training to assist members in acquiring the skills they will need to live independently as adults.
To determine the need for FFSS for independent living, the service coordinator must discuss the member's and primary caregiver's plan for the member's independent living. When identifying the member's need for this service, the service coordinator should address age appropriateness for the tasks required to meet these needs. The service coordinator must determine the amount of FFSS needed to support the member's needs. The service coordinator should discuss the skill level required to assist the member and the appropriateness of the living arrangement and service delivery regarding the member's age, health and welfare. FFSS may be used only when the primary caregiver is working, attending school or participating in job training.
4753 Flexible Family Support Services in Post-Secondary Education
Revision 22-2; Effective September 1, 2022
A member can access flexible family support services (FFSS) to participate in post-secondary education. Post-secondary education institutions do not assist students with activities of daily living (ADL), instrumental activities of daily living (IADL), skilled task, non-skilled task or delegated skilled task needs. If a member has an ADL, IADL, skilled task, non-skilled task or delegated skilled task need prohibiting the member from participating in post-secondary education, the service coordinator may authorize FFSS, so the member may participate in post-secondary education.
A member may enroll in a post-secondary school after first attending a secondary school, such as a high school. A post-secondary education may include vocational education and training, as well as participation in a college or university. These educational institutions are not subject to the Individuals with Disabilities Education Act. Post-secondary institutions can provide academic adjustments, but do not support the member's personal, skilled and delegated skilled task needs.
To determine the need for FFSS in post-secondary education, the service coordinator must identify the member's need for assistance and the amount of FFSS needed to support the member's needs. The service coordinator should identify the member's personal and skilled task needs and the amount of time needed to address those needs. The service coordinator should discuss the skill level required to assist the member and address necessary safeguards to ensure the member's health and welfare.
4754 Flexible Family Support Services Requiring Delegated Tasks
Revision 22-2; Effective September 1, 2022
A delegated task is defined as a task that a physician or registered nurse (RN) delegates in accordance with state law. In general, the Texas Board of Nursing (BON) defines nurse delegation as authorizing an unlicensed person to provide nursing services while retaining accountability for how the unlicensed person performs the task. In brief, the Texas Occupations Code indicates a physician may delegate to a qualified and properly trained person acting under the physician's supervision any medical act that a reasonable and prudent physician would find within the scope of sound medical judgment to delegate. Only a Home and Community Support Services Agency (HCSSA) nurse may delegate to an attendant under their supervision, per BON rules. A member with a skilled task need may use an attendant with delegated tasks if a practitioner or RN delegates the skilled task required to meet the member's needs.
If the member does not have a skilled task need for the delivery of flexible family support services (FFSS), they do not have a need for an attendant with delegated tasks. If the member or primary caregiver requests the use of an attendant with delegated tasks, but the service coordinator or the HCSSA provider determines the use of this provider type places the individual's health and welfare at risk, the service coordinator should not authorize an attendant with delegated tasks to deliver respite, unless determined appropriate by the member's physician.
If a member or their legally authorized representative (LAR) employs an attendant under the Consumer Directed Services (CDS) option, delegation of certain tasks is not required under the CDS option. Form 1585, Acknowledgment of Responsibility for Exemption from Nursing Licensure for Certain Services Delivered through CDS, outlines what services cannot be delegated, such as specific tasks involved in the implementation of the care plan that require professional nursing judgment or intervention. If the member or their LAR is directing the member's services, he must sign Form 1585, acknowledging responsibility for the training and oversight of an attendant.
4760 Flexible Family Support Services Limits
Revision 22-2; Effective September 1, 2022
Flexible family support services (FFSS) may be used only when the primary caregiver is working, attending school or participating in job training, and are delivered in a setting where the delivery of similar supports is not already required or included as part of the service. For this reason, the service coordinator may not authorize FFSS during the same time period the individual receives personal care services (PCS) or Community First Choice (CFC).
42 Code of Federal Regulations §441.301(b)(1)(ii) requires that Medically Dependent Children Program (MDCP) services, including FFSS, may not be provided to a member who is admitted to a hospital, or is a resident of a nursing facility (NF) or intermediate care facility for individuals with an intellectual disability or related conditions (ICF-IID).
The service coordinator may not authorize FFSS during the member's school hours in primary or secondary educational settings.