6100, Home and Community Based Services

Revision 18-2; Effective September 3, 2018

6110 Program Overview

Revision 18-2; Effective September 3, 2018

6111 Service Introduction

Revision 19-1; Effective June 3, 2019

The service array under the STAR+PLUS Home and Community Based Services (HCBS) program is designed to offer home and community-based services as cost-effective alternatives to institutional care in Medicaid certified nursing facilities. Eligible members receive services according to their specific needs, as defined by an assessment process, based on informed choice and through a person-centered process.

Agencies contracted with managed care organizations (MCOs) provide services to members living in their own homes, foster homes, assisted living facilities (ALFs) and other locations where service is needed. The services provided are identified on an individual service plan (ISP) and are authorized by the MCOs, as identified in Section 6113, General Requirements for MCOs, and in accordance with the ISP.

6112 Service Locations for STAR+PLUS HCBS Program

Revision 19-1; Effective June 3, 2019

All services through the STAR+PLUS Home and Community Based Services (HCBS) program, except minor home modifications (MHMs), can be provided to members in locations of their choice. Nursing services, therapy services, adaptive aids (including dental) and medical supplies may be provided to a STAR+PLUS HCBS program member residing in an assisted living facility (ALF) contracted to provide STAR+PLUS HCBS program services. Per Title 42 of the Code of Federal Regulations (CFR), Subpart K, Section 441.530(a)(2), the following locations are excluded from STAR+PLUS HCBS program service locations, with the exception of out-of-home respite care:

  • Nursing facilities (NFs);
  • Psychiatric hospitals;
  • Intermediate care facilities for individuals with intellectual disabilities (ICF/IID);
  • Hospitals providing long term care; and
  • Locations that have the qualities of an institution.

6113 General Requirements for MCOs

Revision 21-2; Effective August 1, 2021

The managed care organization (MCO) must coordinate and ensure delivery and initiation of the array of services in accordance with Form H1700-1, Individual Service Plan. Services include:

  • personal assistance services (PAS);
  • nursing services;
  • physical therapy (PT);
  • occupational therapy (OT);
  • speech therapy (ST) services;
  • cognitive rehabilitation therapy (CRT);
  • adaptive aids;
  • medical supplies;
  • minor home modifications (MHMs);
  • emergency response services (ERS);
  • assisted living (AL);
  • adult foster care (AFC);
  • home-delivered meals;
  • dental services;
  • transition assistance services (TAS);
  • respite care;
  • employment assistance; and
  • supported employment.

The MCO must identify, coordinate and when applicable, authorize available value added services, Medicare and other third-party resources (TPRs) before authorizing those services on the member's individual service plan (ISP). Refer to specific service descriptions for exceptions or limitations.

6114 Service Plan

Revision 21-2; Effective August 1, 2021

The managed care organization (MCO) must authorize all services identified on the individual service plan (ISP). When sending an authorization to a provider, the MCO may send the following:

  • Form H1700-1, Individual Service Plan;
  • Form H1700-2, Individual Service Plan – Addendum;
  • Form H1700-3, Individual Service Plan – Signature Page;
  • Form H1700-A1, Certification of Completion/Delivery of STAR+PLUS HCBS Program Items/Services;
  • Form H2060, Needs Assessment Questionnaire and Task/Hour Guide;
  • Form H2060-A, Addendum to Form H2060;
  • Form H2060-B, Needs Assessment Addendum,
  • Form H6516, Community First Choice Assessment; or
  • Other forms and assessments, as applicable.

The MCO must send any functional assessment documentation to the provider when requested. The MCO will upload the signed Form H1700-3 to the XXXISP folder in TxMedCentral using the appropriate naming convention. If Form H1700-1 is electronic, the MCO will submit Form H1700-1 through the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care (LTC) Online Portal or TMHP Electronic Data Interchange. All other forms are maintained in the member's file folder.

The MCO registered nurse (RN) service coordinator or MCO contracted RN service coordinator and the member or authorized representative (AR) must sign Form H1700-3 prior to the start date of the ISP to certify the proposed ISP accurately reflects the needs of the member.

Verbal authorizations are permitted for ISP changes, as long as the name of the person who gave the verbal authorization and the date the verbal authorization was given, are included on the signature line. The proposed ISP should be presented to the member following development of the proposed ISP and the member should sign Form H1700-3 to indicate acceptance.

6115 Individual Agreement for Services

Revision 18-2; Effective September 3, 2018

Managed care organizations (MCOs) may choose to provide services through other pay arrangements with individuals awaiting determination of STAR+PLUS Home and Community Based Services (HCBS) program eligibility. MCOs will not be reimbursed for services delivered prior to the determination of STAR+PLUS HCBS program eligibility.

The provider cannot be held responsible for deficits or failure in areas not included in the provider’s portion of the member's individual service plan (ISP) when gratuitous care or care by other resources is being provided.

6116 Refusal to Serve Members

Revision 18-2; Effective September 3, 2018

If a provider refuses to serve a member, the reason the provider cannot adequately meet the needs of the member must be stated in writing to the member’s managed care organization (MCO). The reason for provider refusal must be related to the provider’s limitation and not previous experience with the member or discriminated against because of age, disability or gender, etc. The provider must work with the MCO to coordinate alternative provider agency arrangements. The MCO must coordinate the transfer of services on behalf of the member.

6117 Service Planning

Revision 21-2; Effective August 1, 2021

Services and care provided, as identified and authorized on Form H1700-1, Individual Service Plan, must assist the member to attain or maintain the highest practicable physical, mental and psychosocial well-being.

Services provided are tailored to meet the member's goals and needs based upon her or his medical condition, mental and functional limitations, ability to self-manage, and availability of family and other support.

The managed care organization (MCO) must assure the member's informed choice and convenience are incorporated into the planning and provision of the member's care by involved professionals. The service planning process must be person-centered and the individual service plan (ISP) must reflect the member’s goals, needs, strengths and preferences with regard to the manner of delivery of STAR+PLUS Home and Community Based Services (HCBS) program services. Members must be encouraged and allowed to play an active role in determining their ongoing plan of care (POC).

MCOs must recognize and support the member's right to a dignified existence, privacy and self-determination.

6118 Personal Assistance Services

Revision 21-2; Effective August 1, 2021

Personal assistance services (PAS) provide assistance to members in performing activities of daily living (ADLs) and instrumental activities of daily living (IADLs) based on the member’s needs. Most members will receive PAS through Community First Choice (CFC), with the exception of members who are medical assistance only (MAO), or members who also require protective supervision. Protective supervision is not a benefit of CFC.

PAS includes assistance with the performance of ADLs and IADLs necessary to maintain the home as a clean, sanitary and safe environment. PAS is provided to the member, as authorized on Form H1700-1, Individual Service Plan, or as delivered through CFC.

The state allows a member to select a relative or legal guardian, other than a legally responsible individual, to be the member's provider for this service if the relative or legal guardian meets the requirements for this type of service. Federal and state rules prohibit a spouse from being a paid PAS provider.

6118.1 Description of Personal Assistance Services

Revision 19-1; Effective June 3, 2019

  • Personal assistance services (PAS) include, but are not limited to, the following:
    • assisting with basic self-care tasks known as activities of daily living (ADLs). These include, but are not limited to, self-feeding, dressing, bathing, personal hygiene and grooming, transferring, and going to the toilet;
    • assisting with instrumental activities of daily living (IADLs). These are activities that allow an individual to live independently in the community. These include, but are not limited to, cleaning and maintaining the house, preparing meals, shopping for groceries, and taking prescribed medications;
    • providing extension of therapy services;
    • providing assistance with ambulation and balance;
    • assisting with medications that are normally self-administered;
    • performing health maintenance activities, as defined by the Texas Board of Nursing;
    • performing nursing tasks delegated and supervised by a registered nurse (RN), in accordance with the Texas Board of Nursing rules;
    • escorting the member on trips to obtain medical diagnosis, treatment or both; and
    • providing protective supervision.
  • The managed care organization (MCO) must authorize and ensure the provision of PAS as identified on Form H6516, Community First Choice Assessment, or Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, Form H2060-A, Addendum to Form H2060; and Form H2060-B, Needs Assessment Addendum, and authorize PAS, as applicable, to members living in their own homes or other community settings.
  • Activities purchased under PAS are limited to the member’s personal space and solely for the member’s personal needs. The following examples of services not reimbursable under the STAR+PLUS Home and Community Based Services (HCBS) program are:
    • taking care of household non-service related pets;
    • ironing;
    • moving furniture;
    • cleaning windows; and
    • performing yard work other than yard hazard removal.

Shopping

Shopping is intended for the purchase of groceries, medications, or other items that support the health, safety, and well-being of a member. This may be done by the attendant on behalf of the individual or the attendant may accompany the individual to assist with this task. Neither the provider nor the attendant can charge the member for transportation costs incurred in the performance of this task.

Ambulation

Ambulation is a personal care task that involves non-skilled assistance with walking or transferring while taking the usual precautions for safety (that is, standby assistance, gentle support of an elbow for balance or assuring balance of a walker). This does not involve nursing intervention. No special precautions are needed other than for safety measures.

To facilitate safe member ambulation or movement, the attendant may need to ensure safe pathways throughout the home for the member. Examples include those who use wheelchairs, walkers or crutches, or for members with visual impairment. The attendant care provider or member (or authorized representative (AR)) addresses this activity during orientation and on an ongoing basis for an attendant who provides services to a member needing assistance.

The member’s primary care provider (PCP) may request specific ambulation orders. If ambulation is authorized as a nursing task, the service coordinator must not authorize ambulation as a non-skilled task on Form H2060, Form H6516 and any addendums to Form H2060. Authorizing ambulation as a nursing task and at the same time as a non-skilled task is a duplication of services. When completing the functional assessment on Form H2060 and any addendums to Form H2060, the service coordinator must consider the member's need for ambulation. If it appears the member needs both skilled and non-skilled ambulation assistance, the service coordinator must document in the case record why and how the member requires both. The service coordinator can approve both if there is no duplication.

Escort

Escorting is for healthcare-related appointments and does not include the direct transportation of the member, or the receipt or exchange of health information by the attendant. Escort services may be provided for safety needs, to enter or exit a building, or to remain safe during wait time while attending medical appointments. Transportation for Medicaid members to Medicaid appointments is available in every county through the Medical Transportation Program (MTP). Transportation is not included as an activity in the escort task.

Protective Supervision

The purpose of protective supervision is to assure the health and welfare of a member with a cognitive impairment, memory impairment or physical weakness. Protective supervision is authorized by the MCO, and assures supervision of the member during instances in which the member’s informal support is unavailable.

Protective supervision is supervision only and does not include the delivery of personal care tasks. Protective supervision is appropriate when it is necessary to protect the member from injury due to her or his cognitive/memory impairment and/or physical weakness. If left unattended, for instance, the member may wander outside, turn on electrical appliances and burn herself or himself, or try to walk and then fall. Protective supervision is not routinely authorized for members who can safely live on their own, nor is it intended to provide 24-hour care. Protective supervision is not a benefit of CFC and can be on a member’s individual service plan (ISP), even if the member receives CFC.

Exercise

A member may request, or a physician may order, assistance with walking as a form of exercise. A member must be ambulatory for exercise to be an authorized PAS activity.

Therapy Extension

Licensed therapists may choose to instruct the PAS attendant on the proper way to assist the member in follow-up of therapy sessions. This assistance or support provides reinforcement of instruction and aids in the rehabilitative process. Therapy extension is documented on Form H2060-A.

6118.2 Personal Assistance Services Attendants

Revision 19-1; Effective June 3, 2019

Personal assistance services (PAS) are performed by personal care attendants who:

  • are not themselves recipients of PAS;
  • are employed by a managed care organization (MCO) contracted provider or employed by the member or the employer of record under the Consumer Directed Services (CDS) Option;
  • are not the spouses of members;
  • perform all of the services available within their scope of competency;
  • may serve as backup attendants to initiate services, prevent a break in service and provide ongoing service
  • are required to provide services that meet a member’s health and safety needs; and
  • if applicable, meet additional eligibility requirements under the CDS option.