Revision 18-2; Effective September 3, 2018

7110 Introduction

Revision 20-1; Effective March 16, 2020

Adult foster care (AFC) provides 24-hour living arrangements and personal care services and supports for persons who, because of physical or behavioral conditions, are unable to live independently. Services and supports may include assistance and/or supervision with daily living, including meal preparation, housekeeping, companion services, personal care, nursing tasks and provision of, or arrangement for, transportation. The STAR+PLUS Home and Community Based Services (HCBS) applicant or member who chooses AFC must reside with a contracted STAR+PLUS HCBS program AFC home provider that meets the minimum standards and licensure requirements found in Appendix XXIV, Minimum Standards for STAR+PLUS AFC Homes and Home Providers.

AFC home providers must be contracted either directly with the member’s managed care organization (MCO) or with an AFC provider agency contracted with the member’s MCO. The individual qualified to provide AFC (AFC home provider) must be the primary caregiver. AFC home providers must live in the household and share a common living area with the member. Detached living quarters do not constitute a common living area. AFC home providers may serve up to three adult residents in a qualified AFC home without being licensed as a personal care home or assisted living facility (ALF), and may be the AFC home provider’s home or the STAR+PLUS HCBS program applicant’s or member’s home. AFC home providers with four or more residents, which are also contracted with the Texas Health and Human Services Commission (HHSC), are required to have a Type C Personal Care Home license. AFC homes with four to eight AFC residents must be licensed as an ALF, with limitations on the number of residents at each level who may reside in the home. The three levels of eligibility for AFC are explained in 7133, Classification Levels of Adult Foster Care Members. ALF licensure requirements are found in Title 26 Texas Administrative Code (TAC), Chapter 553.

Any reference to “resident” includes members receiving services in the STAR+PLUS HCBS program and AFC or private pay individuals. AFC home providers may serve a combination of STAR+PLUS HCBS program members and private pay individuals in a qualified or licensed AFC home as long as the AFC home provider continues to meet the minimum standards specified in Appendix XXIV, and additional other standards may be specified by the MCO.

When the AFC home provider moves in with the STAR+PLUS HCBS program member receiving AFC in the member’s home, the AFC home enrollment requirements indicated with an asterisk in Appendix XXIV may be waived at the discretion of the MCO or the MCO-contracted AFC provider agency, as appropriate. Other minimum standards, excluding home safety requirements, may be waived at the discretion of the MCO, or upon the recommendation by the MCO-contracted AFC provider agency as long as the MCO-contracted AFC provider agency has completed a home assessment and concluded the member’s needs can be appropriately met through the STAR+PLUS HCBS program and AFC-specific services. Such conclusions must be documented by the MCO-contracted AFC provider agency and approved by the MCO.

The MCO is responsible for ensuring the AFC member receives all necessary AFC services, including the authorization of other needed services and nursing tasks.

STAR+PLUS HCBS program AFC members are required to pay for their own room and board costs and, if able, contribute to the cost of AFC services through a copayment to the AFC home provider. The only time room and board is not required is when the AFC home provider moves in with the member and the member's home becomes the AFC home. Room and board arrangements must be documented in the member’s case file by the MCO or by the MCO-contracted AFC provider agency.

If an AFC home is contracted with HHSC to provide services to an applicant or member receiving AFC through HHSC, the MCO or the MCO-contracted provider agency may request a copy of the AFC home and AFC home provider qualification documents from HHSC, if applicable. These documents contain HHSC findings regarding the qualifications of the AFC home and AFC home provider.

7111 Purpose

Revision 18-2; Effective September 3, 2018

The purpose of the STAR+PLUS Home and Community Based Services (HCBS) program adult foster care (AFC) is to promote the availability of appropriate services in a home-like environment for members who are aging and who have disabilities to enhance the dignity, independence, individuality, privacy, choice and decision-making ability of a member.

The STAR+PLUS HCBS program requires each AFC member to have enough living space to guarantee his or her privacy, dignity and independence.

7112 MCO Contracting Options

Revision 18-2; Effective September 3, 2018

The managed care organization (MCO) provides STAR+PLUS Home and Community Based Services (HCBS) program adult foster care (AFC) through one of the two contracting methods:

If the MCO contracts with an AFC provider agency, the MCO has oversight over the AFC provider agency. The MCO retains responsibility for its member(s).

7113 Adult Foster Care Services

Revision 19-1; Effective June 3, 2019

The adult foster care (AFC) home provider must provide services, supports and supervision, as needed, around the clock in an AFC home that has either been qualified based on the minimum standards or licensed by the Health and Human Services Commission (HHSC) (for homes serving four or more residents). Services may include:

Personal assistance services (PAS) — Help with activities related to the care of the member's physical health that includes but is not limited to bathing, dressing, preparing meals, feeding, exercising, grooming (routine hair and skin care), toileting and transferring/ambulating.

A STAR+PLUS Home and Community Based Services (HCBS) program adult foster care (AFC) member may not receive STAR+PLUS HCBS program PAS while the member is a resident in a STAR+PLUS HCBS program AFC home. Form H6516, Community First Choice Assessment, or Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, and any addendums to Form H2060 are completed by the managed care organization (MCO) to determine the needed tasks for completion by the AFC home provider. The MCO must provide a copy of the required PAS tasks to the AFC home provider and to the MCO-contracted AFC provider agency, if applicable.

Transportation — Arrangement of and/or direct transport of members to meet their basic needs for food, clothing, toiletries, medications, medical care and necessary therapy.

Supervision — Periodic checks or visits by the provider to the member throughout the 24-hour period to assure the member is well and safe. For some members with more intensive medical needs or behavior problems, more frequent supervision is required.

Meal preparation — Preparation or provision of meals adequate to meet the needs of the member.

Housekeeping — Activities related to housekeeping that are essential to the member's health and comfort, such as changing bed linens, housecleaning, laundry, shopping, arranging furniture, washing dishes and storing purchased items.

AFC services, with the exception of 24-hour supervision that is provided to all STAR+PLUS HCBS program AFC members, are provided on an "as needed" basis, with the flexibility to meet the member's needs in the least restrictive way possible. For example, STAR+PLUS HCBS program AFC members may not need assistance with medication or help with transportation, but the services are available to all STAR+PLUS HCBS program members in AFC homes. PAS tasks must be provided as identified on Form H2060 and any addendums to Form H2060. The AFC home provider may provide more services for the member than are authorized, as the changing needs of the member may warrant, but may not reduce or discontinue services without prior consultation with the MCO.

STAR+PLUS HCBS program members, as recipients of Medicaid, are entitled to medical transportation services. Transportation is provided to Medicaid-covered medical appointments. Access to non-emergency medical transportation is available to members through the Medical Transportation program.

7114 Other Long Term Services and Supports Available to Adult Foster Care Members

Revision 21-2; Effective August 1, 2021

The managed care organization (MCO) may provide or arrange for the provision of the following services.

Adaptive Aids and Medical Supplies — Medical equipment and supplies that include devices, controls or appliances specified in the plan of care (POC) that enable individuals to increase their abilities to perform activities of daily living (ADLs) or to perceive, control or communicate with the environment in which they live.

Nursing Services — Services for members may be provided through the STAR+PLUS Home and Community Based Services (HCBS) program. Nursing services are assessment, planning and interventions provided by a person licensed to engage in professional nursing practice as a registered nurse (RN) or licensed vocational nursing (LVN) by the Texas Board of Nursing (BON) or licensed in a state that has adopted the Nurse Licensure Compact.

Minor Home Modifications (MHMs) — Services that assess the need, arrange for, and provide modifications and/or improvements to a residence to enable the member to reside in the community and to ensure safety, security and accessibility. MHMs are limited to those modifications identified and approved by the MCO on the individual service plan (ISP).

If the adult foster care (AFC) home is the member’s home, the member must agree to have modifications made to the home. If the AFC home provider is the owner of the home, the AFC home provider must agree to have modifications made to the home. If the AFC home provider is the lessee of the home, the owner must be contacted and apprised of the needed modifications. Permission to make the modifications must be obtained from the home owner in writing and kept with Form H1700-2, Individual Service Plan – Addendum.

When the AFC home provider and member or STAR+PLUS HCBS program applicant meet to interview each other and complete Form 2327, Individual/Member and Provider Agreement, the MHMs must be listed in "Miscellaneous Arrangements" if the AFC home is not the member’s home. Both the member and the AFC home provider must sign Form 2327 agreeing to all included information and stipulations.

To save the member from spending his or her allocation for MHMs unnecessarily, a minimum grace period of 30 days must be allowed for the member to adjust to the AFC placement before any modifications are begun. If the health or safety of the member is jeopardized without the necessary modifications upon entry into the AFC home, a waiver of the 30 days can be made based on the recommendations of the interdisciplinary team (IDT) and approved by the MCO.

MHMs remain in a STAR+PLUS HCBS program AFC home even if the member for whom the modifications were made permanently leaves the home.

Dental Services — Services provided by a licensed dentist to preserve teeth and meet the dental need of the member.

Occupational Therapy (OT) — Interventions and procedures to promote or enhance safety and performance in the instrumental activities of daily living (ADLs), education, work, play, leisure and social participation. Services consist of the full range of activities provided by an OT or a licensed occupational therapy assistant under the direction of a licensed occupational therapist and within the scope of his/her state licensure.

Physical Therapy (PT) — Specialized techniques for the evaluation and treatment related to functions of the neuro-musculoskeletal systems. Services consist of the full range of activities provided by a physical therapist or a licensed physical therapist assistant under the direction of a licensed physical therapist and within the scope of his/her state licensure.

Speech Therapy (ST) — The evaluation and treatment of impairments, disorders or deficiencies related to a member’s speech and language. Services include the full range of activities provided by a speech and language pathologist under the scope of the pathologist's state licensure.

Cognitive Rehabilitation Therapy (CRT) — A service that assists an individual in learning or relearning cognitive skills that have been lost or altered as a result of damage to brain cells/chemistry in order to enable the individual to compensate for the lost cognitive functions. CRT is provided when determined to be medically necessary through an assessment conducted by an appropriate professional. The assessment is not included under this service provision. CRT is provided in accordance with the plan of care developed by the assessor, and includes reinforcing, strengthening or reestablishing previously learned patterns of behavior, or establishing new patterns of cognitive activity or compensatory mechanisms for impaired neurological systems.

Employment Assistance (EA) Services — Services that assist the member with locating competitive employment or self-employment.

Supported Employment (SE) Services — Services that assist the member with sustaining competitive employment or self-employment.

Day Activity and Health Services (DAHS) — Includes nursing and personal care services, physical rehabilitative services, nutrition services, transportation services and other supportive services. These services are provided at facilities licensed or certified by the Texas Health and Human Services Commission (HHSC).

Each of the above services is provided according to the needs of the member as identified on the ISP, with the exception of DAHS, which is not included on the ISP. The MCO makes referrals for DAHS, coordinates delivery and advises the AFC home provider or MCO-contracted provider agency of any updates to the ISP or referrals for DAHS. Members who have nursing needs may be able to obtain nursing services at a DAHS facility. The MCO service coordinator will work with the AFC home provider or provider agency, if applicable, and the member to determine where the member’s needs can be most appropriately met. STAR+PLUS Home and Community Based Services (HCBS) program members residing in an AFC home without an RN as the AFC home provider may receive up to 10 units of DAHS per week. For Level III AFC homes, refer to 7133.2, AFC Homes Corresponding to AFC Member Levels, for DAHS eligibility.

7120 Minimum Standards for All Adult Foster Care Homes and Home Providers

Revision 18-2; Effective September 3, 2018

All adult foster care (AFC) homes and AFC home providers must be qualified initially and annually thereafter in accordance with the minimum standards outlined in Appendix XXIV, Minimum Standards for STAR+PLUS AFC Homes and Home Providers.

7121 AFC Homes with Four or More Residents and Members

Revision 20-1; Effective March 16, 2020

An adult foster care (AFC) home provider must obtain an assisted living facility (ALF) license if the AFC home provider wants to serve four or more private pay residents and/or members. The AFC home provider may apply for an ALF license from the Texas Health and Human Services Commission (HHSC) Regulatory Services Division. The license must be renewed annually and requires an annual fee. Licensing standards for various types of AL facilities are found in Title 26 Texas Administrative Code (TAC), Chapter 553.

The AFC home provider must submit a copy of the ALF license to the managed care organization (MCO) or MCO-contracted AFC provider agency before being credentialed and upon renewal. The AFC home provider must report to the MCO or MCO-contracted AFC provider agency any problem(s) identified by HHSC Regulatory Services. AFC home providers must meet all applicable requirements in the minimum standards for AFC. AFC home providers with an AL license must serve no more than a total of eight adult residents in a small group home.

AFC homes of four or more residents, without an HHSC contract, are also subject to the following two sets of regulations:

The stricter requirements apply when requirements of the two sets of regulations conflict. For example, an AFC home licensed as a small group home must comply with the requirement that an attendant be present at all times when residents are in the facility. This requirement applies regardless of the number of members currently residing in the facility.

If the MCO uses a contracted AFC provider agency, the contracted AFC provider agency must provide copies of any licenses for AFC homes of four or more residents when the MCO requests them.

7122 Small Homes for One to Three Residents and Members

Revision 18-2; Effective September 3, 2018

An adult foster care (AFC) home provider who serves up to three residents, including STAR+PLUS Home and Community Based Services (HCBS) program members, may be a member's relative, excluding the spouse. While these small homes do not require licensure, AFC homes and AFC home providers must meet the standards found in Appendix XXIV, Minimum Standards for STAR+PLUS AFC Homes and Home Providers. As outlined in 7110, Introduction, if the AFC home provider moves into the AFC member's home, AFC home requirements in Appendix XXIV may be waived at the discretion of the managed care organization (MCO) or MCO-contracted AFC provider agency.

7123 MCO Responsibilities

Revision 19-1; Effective June 3, 2019

The managed care organization (MCO) responsibilities include:

  • providing information to interested applicants about potential adult foster care (AFC) homes and coordinating visits to the homes;
  • developing an individual service plan (ISP);
  • acting as coordinator of the interdisciplinary team (IDT);
  • authorizing AFC services;
  • evaluating and coordinating services for the member;
  • notifying the member, AFC home provider and AFC provider agency, if applicable, of room and board and copayment amounts, as outlined in 3236, Copayment and Room and Board;
  • processing changes and conducting annual reassessments of the member;
  • completing an assessment to ensure the potential or existing member’s needs can be met in a particular home;
  • recruiting, contracting and credentialing AFC homes and home providers;
  • processing AFC home and home provider applications;
  • orienting and training AFC home providers;
  • approving private pay residents;
  • ensuring initial and ongoing compliance with AFC minimum standards;
  • conducting annual re-qualification reviews of the AFC home and home provider;
  • conducting administrative reviews; and
  • processing AFC provider payments.

An MCO may also choose to contract with an AFC provider agency to facilitate AFC home and home provider management on behalf of the MCO. When this occurs, the contracted AFC provider agency is responsible for provisions stipulated in its contract with the MCO. However, the MCO retains overall responsibility for all requirements related to AFC service delivery and oversight of the MCO-contracted AFC provider agency and the member.

7130 Adult Foster Care Eligibility

Revision 18-2; Effective September 3, 2018

To be eligible for adult foster care (AFC), applicants and members must meet basic eligibility requirements for STAR+PLUS Home and Community Based Services (HCBS) program services as well as specific requirements related to AFC. Basic eligibility requirements for the STAR+PLUS HCBS program can be found in 3230, Financial Eligibility, and 3240, Waiver Requirements. AFC applicants or members are identified for the STAR+PLUS HCBS program AFC based on their assessed needs for care. Refer to 7133, Classification Levels of Adult Foster Care Members.

7131 AFC Intake, Assessment and Response to Request for Services

Revision 19-1; Effective June 3, 2019

Adult foster care (AFC) is appropriate for individuals who, because of physical, mental or behavioral conditions, are unable to live independently and who need and desire the support and security of family living. AFC may be appropriate for individuals who are:

  • seeking alternatives to facility-based care; or
  • interested in leaving institutional care but are unable to resume independent living.

When discussing AFC as an option for applicants or members, the managed care organization (MCO) or MCO-contracted AFC provider must explain the room and board requirements and ensure the applicant or member understands that he or she must pay a portion of the monthly income for room and board. If the AFC home provider moves into the member’s home, payment for room and board does not apply. The MCO must also explain that some members residing in an AFC home are additionally required to contribute to the cost of their AFC services by paying a copayment, regardless of whether the AFC home is the member's home. Refer to 7152, Copayment and Room and Board Requirements, for additional information.

7132 Assessing Potential Adult Foster Care Homes

Revision 21-2; Effective August 1, 2021

If the applicant or member appears to meet eligibility criteria, the managed care organization (MCO) or MCO-contracted provider agency provides information to the applicant or member about adult foster care (AFC) services, including potential AFC home providers and AFC homes. The MCO or MCO-contracted AFC provider agency can arrange visits to appropriate AFC homes or, if the applicant or member is capable or has family/supports available, the applicant or member and family may make the arrangements to visit potential AFC homes.

The purpose of the visits to potential AFC homes is to let the applicant or member assess the home and let the AFC home provider assess if the applicant or member will be an appropriate resident for the AFC home. The MCO or MCO-contracted AFC provider agency may contact the AFC home provider and share information about the applicant or member, including the applicant's or member’s particular needs and characteristics, to ensure the potential AFC home provider is fully aware of the responsibilities involved in caring for the applicant or member and to prevent a potential mismatch of the applicant or member and the AFC home provider.

As part of the assessment, MCO service coordinators must determine if the applicant or member can be left alone for up to three hours and document this on Form H1700-2, Individual Service Plan – Addendum. The MCO service coordinator must inform the AFC home provider directly of this or through the MCO-contracted AFC provider agency, if applicable. If the applicant or member cannot be left alone, the AFC home provider will be responsible for providing or arranging for 24-hour supervision.

To guide the applicant or member in the selection of the AFC home, the MCO or MCO-contracted AFC provider agency relies on the recommendation of the registered nurse (RN) completing the STAR+PLUS Home and Community Based Services (HCBS) program assessment regarding the needs of the applicant or member. Refer to 7133, Classification Levels, below. If the MCO is not contracting with an AFC provider agency, the MCO’s RN must also assess the ability of the applicant or member to safely evacuate the AFC home.

7133 Classification Levels

Revision 18-2; Effective September 3, 2018

Classification (payment levels) for adult foster care (AFC) members are used for identification of potential AFC applicant or member appropriateness, and are based on the member’s assessed needs for care as determined through the required face-to-face assessments for STAR+PLUS Home and Community Based Services (HCBS) program services and the individual service plan (ISP) completed by the managed care organization (MCO) service coordinator. Determine and document whether an applicant or member is appropriate for AFC based on the applicant’s or member’s condition and behavior. Develop a service plan appropriate to the applicant’s or member’s needs and specific to a given AFC home provider, taking into consideration the AFC home provider’s capabilities. The MCO-contracted AFC provider agency, if applicable, would be involved in a determination of AFC home provider capabilities.

7133.1 Levels of Adult Foster Care Members

Revision 19-1; Effective June 3, 2019

The managed care organization (MCO) will use the Medical Necessity and Level of Care (MN/LOC) assessment, Form H6516, Community First Choice Assessment, or Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, and addendums. The registered nurse (RN) service coordinator determines a member’s classification level for adult foster care (AFC) services. MCOs must consider a need for limited or greater assistance with the performance of activities of daily living (ADLs) (transferring, walking, dressing, eating, toileting, bathing), and behaviors that occur at least once a week in the assessment and determination, as well as other identified needs of the member.

Below are the classification levels of a member’s daily assistance or supervision requirements.

Level I AFC Member

A member who needs assistance with identified needs including a minimum of:

  • one ADL and behavior(s) that occur at least once a week; or
  • two ADLs.

Level II AFC Member

A member who needs assistance with identified needs including a minimum of:

  • two ADLs and behavior(s) that occur at least once a week; or
  • three ADLs.

Level III AFC Members

A member who needs assistance with identified needs including a minimum of:

  • three ADLs and behavior(s) that occur at least once a week; or
  • four ADLs.

7133.2 AFC Home Provider Corresponding to AFC Member Levels

Revision 19-1; Effective June 3, 2019

The adult foster care (AFC) home provider must be able to meet the member’s needs in the AFC setting in conjunction with the STAR+PLUS Home and Community Based Services (HCBS) program and other available supports. If the member’s needs for care exceed the capability of the AFC home provider, the managed care organization (MCO) service coordinator must reassess the member and offer alternate care options.

The AFC home provider who is a licensed registered nurse (RN) and the AFC home provider RN substitute must provide proof of current licensure to the MCO or MCO contracted provider agency (if applicable) initially and annually thereafter.

The MCO RN service coordinator will complete the Medical Necessity and Level of Care (MN/LOC) assessment, both initially and annually. AFC home providers with STAR+PLUS HCBS program members may not care for more than one totally dependent AFC resident. The MCO RN service coordinator must respond to a request for a change in services within the individual service plan (ISP) year.

Health maintenance activities (HMAs) are tasks which may be exempt from registered nurse delegation based on the MCO RN assessment. HMAs may enable the member to remain in an independent living environment and go beyond activities of daily living (ADLs) because of the higher skill level required to perform them (as found in the Texas Board of Nursing rules in 22 Texas Administrative Code §225.4(8)).

For members residing in Level I, Level II and Level III AFC homes not operated by an RN, the skilled nursing needs must be:

  • identified by the MCO service coordinator as HMAs;
  • purchased as nursing services on the ISP;
  • provided by Medicare, Medicaid home health or other resource;
  • met by a nurse at a Day Activity and Health Services (DAHS) facility; or
  • a combination of the above options.

For members residing in Level I, Level II and Level III AFC homes operated by an RN, the skilled nursing needs must be:

  • identified by the MCO RN service coordinator as HMAs;
  • met by the AFC home provider nurse or nurse substitute;
  • provided by Medicare, Medicaid home health or other resource; or
  • a combination of the above options.

AFC members receiving nursing services and residing with an RN who is the AFC home provider are not eligible to receive day activity and health services (DAHS).

7134 Adult Protective Services and Adult Foster Care

Revision 18-2; Effective September 3, 2018

This section provides details regarding when Adult Protective Services (APS) staff request adult foster care (AFC) as a resource for individuals who may benefit from AFC.

7134.1 Placement of Adult Protective Services Clients in Adult Foster Care

Revision 19-1; Effective June 3, 2019

Adult Protective Services (APS) may want to move an adult foster care (AFC) individual into an AFC home where a STAR+PLUS Home and Community Based Services (HCBS) program member resides. The managed care organization (MCO) must approve and ensure the APS individual is appropriate and document this in the MCO case record. This includes determining the:

  • APS individual's medical and behavioral health needs are met;
  • capacity of the AFC home provider to meet the APS individual's needs; and
  • compatibility of service delivery to the APS individual with the delivery of services to existing AFC members who may reside in the AFC home.

If the MCO determines the APS individual's placement is not appropriate, the APS individual may not move into the AFC home and the APS worker must make other living arrangements.

7134.2 Adult Protective Services Investigations of Adult Foster Care Providers

Revision 19-1; Effective June 3, 2019

Any time managed care organization (MCO) staff of an MCO-contracted adult foster care (AFC) provider agency suspect abuse, neglect or exploitation (ANE) of an AFC member in an unlicensed AFC home, the staff must report it immediately to Adult Protective Services (APS). Reports of ANE in a licensed AFC home must be made to the Texas Health and Human Services Commission (HHSC) Regulatory Services Division. The MCO-contracted AFC provider agency must also notify the MCO.

If reports of ANE taking place in an unlicensed AFC home are made to APS by other parties, the MCO or MCO-contracted AFC provider agency staff may not be notified of member allegations against an AFC provider until after the allegations have been validated. However, APS staff may ask the MCO or MCO-contracted provider agency to assist with the delivery of alternative services during the course of the investigation if the alleged mistreatment poses an immediate threat to the safety of the member or other AFC residents.

The MCO handles disenrollment and corrective actions against the AFC home provider, as appropriate. HHSC takes necessary licensure actions for licensed AFC homes. If HHSC terminates the licensure of an AFC home and the MCO is unable to find a suitable alternative residence for the member, the member is referred to APS for assistance in moving from the AFC home.

A member in an unlicensed AFC home who has the capacity to consent may decide not to move from the AFC home, even though the allegation has been validated. In this instance, the member's AFC services will be denied, payments to the home will terminate and an MCO-contracted provider agency will withdraw from supporting ongoing management of the home. However, the member may continue to reside in the unlicensed AFC home by making private pay arrangements at that home.

If a member residing in an unlicensed AFC home who does not appear to have the capacity to consent refuses to move from an unlicensed AFC home in which an individual identified as the perpetrator in a case of validated ANE lives and is in a state of ANE, the MCO must make a referral to APS. The MCO-contracted AFC provider agency staff must send a referral to the MCO and APS if the agency staff identify this situation.

If the substantiated allegation of ANE is in a licensed AFC home, the perpetrator must be removed from the AFC home and the license holder must submit to HHSC a plan for the protection of the health and safety of all residents. The resident will not be required to move.

7135 Private Pay Individuals in Adult Foster Care

Revision 18-2; Effective September 3, 2018

Some adult foster care (AFC) home providers may wish to take private pay individuals. The AFC home provider must contact the managed care organization (MCO) when considering the admission of a private pay individual before he or she is accepted in the AFC home. The purpose of the approval is to determine the:

  • appropriateness of AFC for the private pay individual based on the individual’s condition and behavior;
  • capacity of the AFC home to meet the private pay individual’s needs; and
  • compatibility of service delivery to the private pay individual and the delivery of services to AFC members.

If the MCO determines placement in an AFC home is inappropriate, the AFC home provider cannot accept the private pay individual. Any issues regarding placements must be resolved by the MCO.

7140 Adult Foster Care Managed Care Organization Procedures

Revision 18-2; Effective September 3, 2018

This section provides details for a managed care organization (MCO) when determining an applicant's eligibility for adult foster care (AFC) and for developing the applicant’s individual service plan (ISP).

7141 Eligibility Determination

Revision 18-2; Effective September 3, 2018 

To determine eligibility for adult foster care (AFC), the managed care organization (MCO) must determine the applicant or member meets all criteria for the STAR+PLUS Home and Community Based Services (HCBS) program and complete an assessment to determine the applicant’s or member’s classification level. If the AFC placement is with an individual AFC home provider contracted with the MCO, the MCO must also ensure the applicant or member has an agreement with an enrolled AFC home provider and the applicant or member and AFC home or home provider are appropriately matched per the classification and needs of the applicant or member before the MCO pays for AFC services. If an MCO contracts with an AFC provider agency to perform AFC management services, the MCO-contracted provider agency may perform activities related to the qualification of the home and the home provider before the MCO pays for AFC services. Refer to 7133, Classification Levels.

7142 Service Planning

Revision 19-1; Effective June 3, 2019

The member’s plan of care must address functional, medical, social and emotional needs and how the needs will be met by the adult foster care (AFC) home provider. The managed care organization (MCO) must assess whether other resources in the community should be used to meet specialized needs of the member. Use of those resources must be documented in the member’s plan of care.

The MCO must complete Form H6516, Community First Choice Assessment, or Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, Part A, Functional Needs Assessment, to document the specific personal assistance tasks with which the AFC home provider must assist the member. The AFC home provider may provide more services for the member than are identified on Form H2060 as the changing needs of the member may warrant, but may not reduce or discontinue services without consultation with the MCO or MCO-contracted AFC provider agency.

Upon approval for AFC, the MCO determines if the member has any special needs that require additional monitoring in the AFC home. The MCO must document any special needs or interventions in the case record on Form 2327, Individual/Member and Provider Agreement. Use the "Other Special Arrangements" space under the "Miscellaneous Arrangements" section.

The MCO or MCO-contracted AFC provider agency contacts the member and the AFC home provider to arrange for the initial visit and a negotiated move-in date for the member or AFC home provider. If there are health concerns regarding the member, the MCO nurse may be consulted and a recommendation may be made for the member to have a physical or medical exam before moving into the AFC home. The MCO coordinates with the interdisciplinary team (IDT) and the MCO-contracted AFC home provider, if applicable, regarding the AFC member’s care.

7150 Finalizing the Member’s Plan of Care

Revision 19-1; Effective June 3, 2019

On or before the date the member begins to receive adult foster care (AFC) services, a face-to-face meeting with the member and the AFC home provider is required to discuss the member's plan of care (POC) and to complete Form 2327, Individual/Member and Provider Agreement. The interdisciplinary team (IDT), including the staff of the managed care organization (MCO)-contracted AFC provider, as applicable, and the member and/or family, authorized representative (AR) or guardian may be included in the meeting. The meeting should preferably take place in the AFC home.

The MCO must discuss the member's POC with the member and/or family, AR or guardian and reach understanding with them about how the AFC home provider will meet the member’s needs. This discussion should ensure the member and family, AR or guardian that the AFC home provider is adequately prepared to provide services to the member and that adjustments occur smoothly. The MCO must document the POC and any special needs of the member or special agreements between the member and AFC home provider on Form 2327.

If the applicant or member is already residing in the AFC home, Form 2327 must be completed by the MCO service coordinator face-to-face with the applicant or member and AFC home provider or provider agency, if applicable, before the MCO pays for AFC services initially and upon annual reassessment.

7151 Member and AFC Home Provider Agreement

Revision 19-1; Effective June 3, 2019

The managed care organization (MCO) documents the service arrangements and the agreement of the room and board payment on Form 2327, Individual/Member and Provider Agreement.

The MCO or the MCO-contracted adult foster care (AFC) provider agency reviews all of the information on the agreement with the member, family, authorized representative (AR) or guardian and the AFC home provider. All conditions of the agreement and the following topics must be covered in the discussion:

  • A full description of the care needs of the member and frequency of services needed.
  • The need for and frequency of supervision.
  • The beginning and ending date on Form 2327.
  • A detailed description of the rights and responsibilities of the member and the AFC home provider.
  • An explanation of the member's and AFC home provider's right to privacy and confidentiality.
  • The monthly dollar amount the member agrees to pay the AFC home provider for room and board, as documented on Form 2327.
  • The arrangements for a trust fund if the STAR+PLUS Home and Community Based Services (HCBS) program member requests such service from the AFC home provider. 
  • An inventory of the AFC member’s personal belongings.
  • The names, addresses and telephone numbers of the persons to be notified in an emergency, including the member's physician, family members and/or AR or guardian.
  • Any special habits and needs of the member and any special arrangements or agreements between the member and the AFC home provider.
  • Any additional training needs of the AFC home provider and methods to obtain that training.
  • The rights and responsibilities of both the member and the AFC home provider for notifying the MCO, MCO-contracted AFC provider agency, as applicable, of problems such as illnesses, adverse medication reactions, hospitalizations, acts of violence, accidents or complaints about abuse, neglect or exploitation. The Texas Health and Human Services Commission (HHSC) Managed Care Compliance & Operations (MCCO) must be notified if the member, MCO-contracted provider agency or AFC home provider have a complaint or issue regarding the health and safety of the member.
  • Other conditions that reflect changes in the member's condition that might affect the appropriateness of AFC services.

The MCO or MCO-contracted provider agency must fully discuss with the AFC home provider the potential for transition issues arising after the member moves into the AFC home or when the AFC home provider moves into the member’s home. The discussion should include notification procedures and suitable actions to be taken to address issues and resolve problems, and the impact of a new living situation on family and other residents in the home.

The member and the AFC home provider must sign Form 2327 after all of the above issues are discussed and both parties are in agreement. Form 2327 must be completed and signed before authorizing and reauthorizing AFC. Any significant changes to the terms of the agreement must be reported by the AFC home provider within five business days. Any incidents, as referenced in Appendix XXIV, Minimum Standards for STAR+PLUS AFC Homes and Home Providers, must be reported by the AFC home provider to the MCO service coordinator assigned to the member, and the MCO-contracted AFC provider agency, as applicable, within 24 hours of the occurrence.

7152 Copayment and Room and Board Requirements

Revision 23-2; Effective June 30, 2023

Copayment and room and board are applicable to adult foster care (AFC) members as described in 3236, Copayment and Room and Board. If the AFC service is provided in the member’s own home, the member is not required to pay room and board. It is the responsibility of the managed care organization (MCO) to ensure the member and the MCO-contracted AFC provider agency, as applicable, are notified in writing on Form 2327, Individual/Member and Provider Agreement, when room and board is waived. It is the MCO-contracted AFC provider agency’s responsibility to notify the AFC home provider when room and board is waived. Copayment, if applicable to the member, may be waived.

If copayment is applicable, the AFC member's copayment amount is listed on Form H2065-D, Notification of Managed Care Program Services, which is sent to the member by Program Support Unit (PSU) staff and uploaded to MCOHub. Form H2065-D is used to report to the member the amount of the copayment for the first month of authorized service and subsequent months. The MCO furnishes a copy of Form H2065-D to the AFC home provider.

The room and board amount, as applicable, is entered on Form H2065-D and Form 2327. The member does not pay room and board if the AFC home provider moves in with the member into the member’s home. The MCO or MCO-contracted AFC provider agency must ensure the member and AFC home provider understand that the room and board arrangement with the AFC home provider is separate from the MCO payment for AFC services. The member pays the AFC home provider the room and board amount listed on Form 2327 and Form H2065-D. If the member is moving into the AFC home mid-month, the amount of room and board for the month is prorated and the member and AFC home provider will be advised of the prorated amount.

When the copayment and/or room and board amounts change, the MCO must notify the AFC home provider and the member of the new amount before the change, as described in 3239, Copayment Changes. The member must pay the copayment and room and board charge by the eighth day of the month. If the member does not pay the required fees, the member may not be eligible for STAR+PLUS Home and Community Based Services (HCBS) program AFC services.

The STAR+PLUS HCBS program AFC home provider must collect the copayment from the member. The AFC home provider must keep receipts for all copayments collected. The AFC home provider must deduct the copayment amount authorized on Form H2065-D from reimbursement claims submitted to the MCO or advise the MCO-contracted AFC provider agency of the amount collected. If a STAR+PLUS HCBS program AFC member does not pay the copayment and/or room and board, the MCO or MCO-contracted AFC provider agency must investigate the member's failure to pay, including contacting the member to learn the reason the fees were not paid. Even if there is a legitimate reason, such as the member's income check has not been received by the eighth day of the month, the member is still under obligation to pay the fees. Grievances between the member and the AFC home provider are not legitimate reasons for the member to withhold payments due. Such grievances must be resolved through the intervention of Texas Health and Human Services Commission (HHSC) Managed Care Compliance & Operations (MCCO) and the MCO.

If the member refuses to pay the fees or there is no legitimate reason for failing to pay, the MCO shall write a letter to the member or the member's authorized representative (AR) explaining the consequences of continued refusal to pay. If the member does not pay the required fees within 30 days of the due date, the MCO can terminate AFC services to the member. If STAR+PLUS HCBS program AFC is being delivered in the AFC home provider’s residence, the member can then be evicted from the home, according to local eviction ordinances and procedures.

7153 Trust Funds

Revision 19-1; Effective June 3, 2019

The managed care organization (MCO) must offer money management assistance by the adult foster care (AFC) home provider to the member and document when the member either accepted or refused the assistance. If the member expresses an interest in money management, the MCO documents the expressed interest on Form H2067-MC, Managed Care Programs Communication, and sends the form to the AFC home provider. The requirement for money management services may also be documented on Form 2327, Individual/Member and Provider Agreement.

The AFC home provider must maintain trust fund records. The AFC home provider must:

  • have written permission from the member, his or her guardian, power of attorney, or applicable individual to handle the member’s personal financial affairs;
  • keep member trust accounts separate from the AFC home provider's operating accounts. The separate account must be identified "Trustee (name of the STAR+PLUS Home and Community Based Services (HCBS) program AFC home provider), Member's Trust Fund Account." If the AFC home provider maintains a trust fund, the AFC home provider must:
    • deposit the member's monthly income into the account; and
    • write a check for the copayment and the room and board payment out of the trust fund account into the AFC home provider's operating account. Staff must not deposit the member's monthly income into the operating account and then deposit the personal needs and room and board allowance into the trust fund account;
  • make the member trust fund records available for review by the MCO or AFC home provider agency during work hours without prior notice;
  • not charge the member for services the AFC home provider is expected to provide for the member;
  • not charge the member for banking service costs if the member’s trust fund is in a pooled account;
  • obtain and maintain current written individual records of all financial transactions involving the member's personal funds that the AFC home provider is handling. The AFC home provider must include at least the following in the records:
    • member's name;
    • identification of member's representative payee or responsible party;
    • admission date;
    • member's earned interest; and
    • transactions – the AFC home provider may choose one of the following options:
      • maintain records of the date and amount of each deposit and withdrawal, the name of the person who accepted the withdrawn funds and the balance after each transaction. Each withdrawal must be signed by the member. If the member is unable to sign when funds are being withdrawn from his/her trust funds, the transactions or receipt must be signed by a witness other than the AFC home provider or employee/contractor of the provider; or
      • maintain signed receipts indicating the purpose for which any withdrawn funds were spent, the date of expenditure and the amount spent. The receipt must be signed by the person responsible for the funds and the member. If the member is unable to sign his or her name, a witness other than the AFC home provider, employee or contractor of the provider must sign the transaction or receipt; and
  • distribute the interest earned on any pooled interest banking account in one of the following options:
    • prorated to each member on an actual interest earned basis; or
    • prorated to each member on the basis of his or her end-of-quarter balance.

The following information must be included on the receipt for all money that is received or deposited in the member’s trust fund:

  • member's name;
  • date the money was received;
  • source of the money;
  • amount received; and
  • amount returned to the member, if any.

All records pertaining to the member's trust fund must be kept in the manner designated above, and available for monitoring without notice.

7154 Hospital Leave

Revision 18-2; Effective September 3, 2018

If a member is receiving adult foster care (AFC) services in an AFC home which is not the member’s home, the member may be required to reserve the space during hospital stays by paying the daily bed hold charge, if the provider requires such a charge, which is the negotiated daily rate the managed care organization (MCO) pays the AFC home provider or MCO-contracted provider agency. The AFC home provider does not bill the MCO for the days the STAR+PLUS Home and Community Based Services (HCBS) program AFC member is hospitalized. The AFC member's bed hold charge constitutes the entire payment to the AFC home provider or MCO-contracted AFC provider agency when an AFC member is hospitalized.

During the initial home visit, the MCO or MCO-contracted AFC provider agency reviews the information regarding the AFC member's responsibility to pay a bed hold charge when away from the home and documents this on Form 2327, Individual/Member and Provider Agreement. Hospital leave does not apply when the AFC home provider moves into the member’s home.

7155 Authorization of Adult Foster Care

Revision 21-2; Effective August 1, 2021

After STAR+PLUS Home and Community Based Services (HCBS) program eligibility is established and all additional adult foster care (AFC) procedures are completed, the managed care organization (MCO) authorizes AFC on Form H1700-1, Individual Service Plan. Program Support Unit (PSU) staff send the member Form H2065-D, Notification of Managed Care Program Services.

The MCO sends the following completed documents to the AFC home provider and MCO-contracted AFC provider agency, if applicable:

  • a copy of Form H1700-1;
  • additional applicable ISP forms:
    • Form H1700-2, Individual Service Plan – Addendum;
    • Form H1700-3, Individual Service Plan – Signature Page; or
    • Form H1700-A1, Certification of Completion/Delivery of STAR+PLUS HCBS Program Items/Services;
  • Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, or Form H6516, Community First Choice Assessment;
  • Medical Necessity and Level of Care Assessment; and
  • Form 2327, Individual/Member and Provider Agreement.

7160 Monitoring Quality of Care

Revision 19-1; Effective June 3, 2019

The managed care organization (MCO) registered nurse (RN) service coordinator will monitor the quality of care and services provided to meet the needs of the STAR+PLUS Home and Community Based Services (HCBS) program members receiving adult foster care (AFC) services. The service coordinator will appropriately address any issues identified to protect the health and safety of the member.

During regular monitoring visits, the MCO RN service coordinator must contact the MCO management and MCO-contracted AFC provider agency, if applicable, if the AFC home provider is not meeting the member's needs or the home provider requires additional support or training to meet the member’s needs. The AFC member's physical and medical condition must be carefully monitored to determine whether initial problems are resolved and/or whether new problems are arising due to decreased functional capacity or illness.

Form 2327, Individual/Member and Provider Agreement (see No. 1 under Miscellaneous Arrangements), is used to document special monitoring schedules and other resources used in the plan of care (POC). When the AFC home provider moves in with the AFC member, it is the MCO's responsibility to ensure the AFC member's needs are being met, and there are no health and safety concerns. If concerns are reported or identified, the AFC member's rights must be protected and adjustments to the care plan made accordingly.

7170 Significant Changes

Revision 18-2; Effective September 3, 2018

It is the joint responsibility of the managed care organization (MCO) and the contracted adult foster care (AFC) home provider, or MCO-contracted AFC provider agency, to ensure the AFC member is in an appropriate setting to meet his or her needs. When the AFC member has a change in functional need, medical status or behavior, it is the responsibility of the AFC home provider to notify the MCO or MCO-contracted AFC provider agency within 24 hours. The MCO must follow up with the member and AFC home provider to determine if changes to the care arrangement are needed.

The MCO must give particular attention to members who have significant changes in functional need, medical status or behaviors that may mean AFC services are no longer appropriate. Family members and/or authorized representative (AR) or guardian must be alerted to these changes, and the MCO service coordinator should discuss with them and the member the potential for the member to remain in the AFC home. If the member has had a decline in his or her medical condition or functional ability, the MCO RN service coordinator should determine if a visit should be made to assess the member’s medical status.

Long-range care plans must be discussed fully with the member and/or family, AR or guardian and the AFC home provider to ensure that all are aware of the capabilities and limitations of AFC services for members with deteriorating medical or functional conditions. Members who become inappropriate for AFC must be advised of other available options. Assistance must be provided to members and family, AR or guardian in this decision process and with transfer activities when necessary. If the AFC home provider decides the member is no longer appropriate for AFC, the AFC home provider must contact the MCO. The MCO is responsible for preparing the member for transition when the member becomes inappropriate for a particular AFC home or AFC services.

7171 Termination of Adult Foster Care Services

Revision 23-2; Effective June 30, 2023

During the course of a member's stay in an adult foster care (AFC) home, the member may experience changes in his or her condition or the care required. If the member begins to need services that cannot be provided by the AFC home provider, the managed care organization (MCO) must consult with the AFC home provider regarding increased needs of the member to assure the necessary care is obtained. Another provider, such as a Home and Community Support Services Agency (HCSSA), may deliver skilled care in the AFC home.

If the skilled services provided in the home by the provider, such as an HCSSA, are not sufficient and other services are not available to support the member, the MCO, in conjunction with other members of the interdisciplinary team (IDT), should explore alternatives.

The AFC home provider is expected to take actions necessary if the member's condition deteriorates or the member is a threat to his or her own health and safety or the health and safety of others. The AFC home provider is required to notify the MCO and MCO-contracted AFC provider agency, as applicable, of actions taken on the same day of awareness. If necessary, the MCO must follow the procedures identified in 7172, Discharge and Termination Due to Health and Safety.

AFC home providers cannot reduce or terminate AFC services to members without the prior approval of the MCO and must follow procedures for providing a 30-day written notice, with an exception for a member whose behavior or condition threatens the health or safety of him or her or others. During the 30 days after written notice is provided to the member, the MCO is responsible for working with the member to assure alternative services are available.

Once a member is identified as inappropriate for AFC, the MCO must negotiate a time frame with the member, family, authorized representative (AR) or guardian and the AFC home provider for the member to have an alternate individual service plan (ISP). The time frame is determined on a case-by-case basis depending on the urgency and severity of the situation and how quickly an appropriate placement can be arranged. If the member has been a threat to the health and safety of other(s) or has exhibited inappropriate behaviors where the member must move immediately, the MCO must make every effort to locate another living arrangement as soon as possible. If other living arrangements are not readily available for the member, the MCO must refer the member to Adult Protective Services (APS) to assist in locating appropriate placement.

If there is resistance to the move from the member, family, AR, guardian or the AFC home provider, additional support from the IDT may be required to resolve the problem. The MCO advises Program Support Unit (PSU) staff to send the member Form H2065-D, Notification of Managed Care Program Services, by uploading Form H2067-MC, Managed Care Programs Communication, to MCOHub to deny AFC services. The MCO follows up on this PSU action by advising the member and AFC home provider of the AFC services termination date specified on Form H2065-D. If the member transfers to another AFC home or STAR+PLUS Home and Community Based Services (HCBS) program living arrangement, the MCO must notify the member and AFC home provider of the change in services. If the member does not transfer to another AFC or STAR+PLUS HCBS program living arrangement and all STAR+PLUS HCBS program services are terminated, the MCO informs PSU staff by uploading Form H2067-MC to MCOHub. PSU staff send the member Form H2065-D and uploads a copy of the form to MCOHub within three business days of uploading Form H2067-MC. If services are not provided in the member’s home, the AFC home provider has the right to begin eviction proceedings as specified in the AFC home provider's resident rights and responsibilities. The MCO must ensure that the member and authorized representative understand the consequences of eviction. If the AFC home provider must use eviction procedures and the member has refused to make other living arrangements, the MCO must refer the member to APS.

If the member and AFC home provider decide that the member will remain in the home as a private pay member, the MCO must give approval. The MCO must also ensure the member and AFC home provider understand that there are no case management services or payment arrangements from the MCO for a private pay member.

Refer to Section 7172, Discharge and Termination Due to Health and Safety, below for more details on how to handle situations in which the AFC member threatens the health and/or safety of himself or herself or others in the AFC home.

7172 Discharge and Termination Due to Health and Safety

Revision 18-2; Effective September 3, 2018

Any member residing in the adult foster care (AFC) home provider’s residence, whose medical condition or behavior or mental health threatens the health and/or safety of him or her or others, is subject to discharge without notice from the AFC home.

The AFC home provider must take appropriate action if the member's medical condition deteriorates and requires more skilled intervention to ensure the member’s health and safety. Depending on the member's condition, appropriate action could include calling emergency medical services, the member's physician or the managed care organization (MCO) service coordinator working with the member or MCO-contracted AFC provider agency, as applicable. The AFC home provider must take action and must inform the MCO on the same day the AFC home provider becomes aware of the need to respond to a change in the member's medical condition.

The MCO must work with the AFC home provider or with providers of other services to arrange alternate services to meet the member's needs.

When the member's behavior causes the member to threaten the health and safety of him or her or others, the AFC home provider must take appropriate action which may include calling the police or sheriff's department, the member's physician, and does include the MCO service coordinator or MCO-contracted AFC provider agency, as applicable. The member must be removed from the AFC home as soon as possible if the member becomes a threat to the health or safety of him or her or others. In some instances, the MCO may call Adult Protective Services (APS) if hospitalization for psychiatric observation seems warranted.

The MCO must issue an Adverse Determination letter to the member within three days of receiving information regarding an incident which warranted the involuntary removal of the member from the AFC home. The effective date on the Adverse Determination letter is the date the form is dated and mailed/given to the member, even if the decision is appealed. Though the member may not be denied all services through the STAR+PLUS Home and Community Based Services (HCBS) program, the member has a right to appeal the decision of removal from the AFC home.

The member may not remain in the STAR+PLUS HCBS program AFC home during the appeal process. The MCO must work with APS or providers of other STAR+PLUS HCBS program services to arrange alternate placement for the member.

In circumstances in which the AFC home provider has moved in with the AFC member into the member’s home, the AFC member has the right to request termination of the arrangement at any time by contacting the MCO or MCO-contracted AFC provider, and request assistance with eviction of the AFC home provider. The MCO must ensure other STAR+PLUS HCBS program service options are offered should the AFC arrangement terminate.

7180 Annual Reassessment of the AFC Member

Revision 19-1; Effective June 3, 2019

In addition to the regular reassessment for the STAR+PLUS Home and Community Based Services (HCBS) program, which includes the managed care organization (MCO) registered nurse (RN) service coordinator completing the Medical Necessity and Level of Care, Form H6516, Community First Choice Assessment, or Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, and addendums, and the individual service planning (ISP) documents, the MCO or MCO-contracted adult foster care (AFC) provider agency must also continue to meet all eligibility requirements and complete Form 2327, Individual/Member and Provider Agreement.