7200, Assisted Living Services

Revision 18-2; Effective September 3, 2018

7210 Introduction

Revision 19-1; Effective June 3, 2019

This section applies to the STAR+PLUS Home and Community Based Services (HCBS) program. Assisted living (AL) services provide a 24-hour living arrangement for persons who, because of physical or mental limitation, are unable to continue independent functioning in their own homes. Services are provided in personal care facilities licensed by the Texas Health and Human Services Commission (HHSC). STAR+PLUS HCBS program members are responsible for their room and board costs and, if applicable, copayment for AL.

The purpose of AL services is to promote the availability of appropriate services for elderly and disabled persons in a home-like environment to enhance the dignity, independence, individuality, privacy, choice and decision-making ability of the individual. The personal care facility must provide each individual a separate living unit to guarantee their privacy, dignity and independence.

7211 Housing Options in Licensed Personal Care Facilities

Revision 19-1; Effective June 3, 2019

The assisted living (AL) apartment may be an efficiency or one or two bedroom apartment, and each apartment must have a private bath and cooking facilities. An AL non-apartment setting is defined as a licensed personal care facility which has living units that do not meet the definition of an AL apartment, may be double occupancy, and must be:

  • freestanding; and
  • licensed for 16 or fewer beds.

STAR+PLUS Home and Community Based Services (HCBS) program AL contracts specify whether the facility has contracted to provide services under the housing options of AL or AL Non-Apartment. The provider may not deliver STAR+PLUS HCBS program services in a housing option for which the provider does not have a contract to deliver services. If a provider wishes to maintain both AL (single occupancy) and AL apartments (double occupancy) in one facility, the member’s contract must specify that information.

If the AL provider wishes to limit the types of apartments in the facility available to STAR+PLUS HCBS program members, the provider must specify these limitations in the contract, either at the time of signature or by amendment. The apartments in question must meet all qualifications as specified in this section. If there are no such specifications in the contract, all types of apartments in the facility must be available to STAR+PLUS HCBS program members.

If the provider limits the type of apartment available for STAR+PLUS HCBS program members and there is no apartment of that size available, they can refuse to accept any STAR+PLUS HCBS program member, based on not having space available. This would apply both for a member wanting to move into the facility from the outside, or to a private pay member currently in the facility who is becoming a STAR+PLUS HCBS program member. The member would then have the option of reviewing other available AL facilities (ALFs) in the area or adult foster care (AFC) homes.

"Freestanding" is defined as not physically connected to a licensed nursing facility, hospital or another licensed personal care facility, unless the total licensed capacity of both personal care facilities does not exceed 16 beds. At minimum, a covered walkway between buildings is required for physical connection.

At the member's request, portable kitchen units may be removed from the living area.

7211.1 Single Occupancy Apartments

Revision 19-1; Effective June 3, 2019

An assisted living (AL) apartment setting is defined as an apartment for single occupancy that is a private space with individual living and sleeping areas, a kitchen, bathroom and adequate storage space, as specified in the following:

  • The apartment must have a minimum of 220 square feet, not including the bathroom. Apartments in pre-existing structures being remodeled must have a minimum of 160 square feet, not including the bathroom.
  • The kitchen is an area equipped with a sink, refrigerator, a cooking appliance that can be removed or disconnected, adequate space for food preparation and storage space for utensils and supplies. A cooking appliance may be a stove, microwave or built-in surface unit.
  • The bathroom must be a separate room in the individual's living area with a toilet, sink and an accessible bath.
  • The bedroom must be single occupancy except when double occupancy is requested by the member.

7211.2 Double Occupancy Apartments

Revision 18-2; Effective September 3, 2018

An assisted living (AL) apartment must be a double occupancy apartment with a connected bedroom, kitchen and bathroom area that provides a minimum of 350 square feet of space per participant, and meet the following specifications:

  • Indoor common areas used by STAR+PLUS Home and Community Based Services (HCBS) program members may be included in computing the minimum square footage. The portion of the common area allocated must not exceed usable square footage divided by the maximum number of individuals who have access to the common areas.
  • The kitchen must be equipped with a sink, refrigerator, a cooking appliance that can be removed or disconnected, adequate space for food preparation and storage space for utensils and supplies. A cooking appliance may be a stove, microwave or built-in surface unit.

7220 Description of Services

Revision 19-1; Effective June 3, 2019

The assisted living facility (ALF) must provide 24-hour care in a personal care facility licensed by the Texas Health and Human Services Commission (HHSC). Services include, but are not limited to:

  • Home management — Assisting with activities related to housekeeping that are essential to the member's health and comfort, including changing bed linens, housecleaning, laundering, shopping, storing purchased items and washing dishes.
  • Transportation and escort — Providing and/or arranging for transportation to:
    • local community shopping areas where a member may purchase items to meet his or her personal needs;
    • recreational activities, field or community trips; and
    • the nearest available provider that can provide medical care which may include medical appointments, therapies and other medical care, unless arrangements are made to transport the member to the medical care provider of the member's choice. Licensure as a personal care facility requires the facility to provide soap and toilet tissue at all times for member use. Other personal items must be purchased by the member. STAR+PLUS Home and Community Based Services (HCBS) program members receiving assisted living (AL) are entitled to receive medical transportation services through Medicaid for Medicaid-covered medical appointments. The ALF personnel are responsible for scheduling the transportation according to medical transportation procedure. If the STAR+PLUS HCBS program member wishes to attend an activity outside the facility, which is not a group activity sponsored by the facility, the member is responsible for paying for his or her own transportation.
  • 24 - Hour supervision — Periodic checks or visits to a member during each eight-hour shift to ensure that the member is safe and well.
  • Meal services include:
    • planning, cooking and serving three meals per day that are essential to the member's health and well-being. The meals must:
      • be suitable in quantity and adequacy to attain and maintain nutritional requirements, including those of special needs members; and
      • supply 100% of the recommended daily dietary allowance for adults, as recommended by the United States Department of Agriculture (USDA);
    • providing special diets, as required by the member's service plan;
    • offering dietary counseling and nutrition education for the member;
    • assisting the member with his or her meals, if necessary, which includes food texture modification, including grinding meats and mashing vegetables for members having trouble chewing; and
    • food management, including assistance with spoon feeding in instances when the member is temporarily ill, bread buttering, and milk opening for members with hand deformities, paralysis or hand tremors.
  • Social and recreational activities include:
    • organizing activities that require group and member-initiated activities;
    • providing opportunities to interact with other people;
    • providing interaction, cultural enrichment, educational or recreational activities, and other social activities on site or in the community in a planned program to meet the social needs and interests of the members;
    • providing four scheduled social activities per week; and
    • posting a monthly social or recreational activity at least one week in advance.

Personal care tasks must be provided, as identified on Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, or Form H6516, Community First Choice Assessment, identified on the individual service plan (ISP) and approved by the MCO. A registered nurse (RN) must perform the medication administration assessment.

The AL provider is responsible through its licensure requirements for providing the administration of medications, which is the direct administration of all medications, or the assistance with or supervision of medication. This includes injections, if needed. Only a licensed nurse can give injections. The personal care facility may provide more services for the member than are identified in the ISP, but not fewer services.

7221 Requirements Related to Assisted Living

Revision 19-1; Effective June 3, 2019

STAR+PLUS Home and Community Based Services (HCBS) program members who wish to reside in a personal care facility must reside in a licensed assisted living facility (ALF) facility which is contracted with the managed care organization (MCO) to provide STAR+PLUS HCBS program services. Licensing rules define a personal care facility as a facility that provides food, shelter and personal care services to four or more persons who are unrelated to the owner. The member is required to pay room and board, and possibly a copayment based on income in the assisted living (AL) setting. Refer to Section 3230, Financial Eligibility, for detailed information.

7222 Initial Responsibilities for Members Residing in ALFs

Revision 21-2; Effective August 1, 2021

The managed care organization (MCO) is responsible for helping the applicant or member select an assisted living facility (ALF) that can meet his or her needs. The MCO sends an authorization to the ALF that the applicant or member selects.

The ALF staff must explain the copayment requirement and room and board charges, described in 3236, Copayment and Room and Board, and Appendix VI, STAR+PLUS Inquiry Chart, to the applicant or member. Room and board must be paid by every STAR+PLUS Home and Community Based Services (HCBS) program ALF applicant or member. A copayment is not required of Supplemental Security Income (SSI) recipients. A copayment is required from those AL members whose financial eligibility was determined under the special institutional criteria. The MCO must:

  • determine the applicant's or member's room and board and copayment amounts, based on the Form H2065-D, Notification of Managed Care Program Services, received from Program Support Unit (PSU) staff, for the initial month of service and ongoing copayment amount for subsequent months;
  • document the amounts on Form H1700-1, Individual Service Plan;
  • verbally notify the applicant or member;
  • send a copy of Form H2065-D to the provider as notification of the amounts to be collected; and
  • assist the applicant or member and provider in resolving problems related to collection of the applicant's or member's copayment and room and board contributions.

Refer to Section 3236 for copayment and room and board guidance.

7223 Admission to an Assisted Living Facility

Revision 21-2; Effective August 1, 2021

Before admission, the managed care organization (MCO) faxes or mails to the assisted living facility (ALF):

The STAR+PLUS Home and Community Based Services (HCBS) program ALF provider is expected to provide to the new member a tour of the ALF, including staff and resident introductions. Members are encouraged to bring basic furnishings for bedroom areas with them.

In the event the member does not provide his or her own furnishings, the facility must provide for each member:

  • a bed with mattress;
  • chair;
  • table or dresser;
  • drawer space; and
  • enclosed closet space for clothing and personal belongings.

Furnishings provided by the ALF must be maintained in good repair.

7224 Personal Care 3

Revision 21-2; Effective August 1, 2021

STAR+PLUS Home and Community Based Services (HCBS) program applicants or members with heavy personal care needs who choose to reside in assisted living (AL) non-apartment settings may be approved for Personal Care 3 level services. Classification of a STAR+PLUS HCBS program applicant or member at the Personal Care 3 level is based on the applicant or member's assessed needs, as evidenced by a value of two or greater in one or more of the activities of daily living (ADLs) of transferring, eating or toileting, as assessed on the Medical Necessity and Level of Care (MN/LOC) Assessment, Section G, Physical Functioning and Structural Problems, Column A, Self-Performance.

During the initial pre-enrollment assessment and annual reassessment, the managed care organization (MCO) nurse completes the MN/LOC Assessment and uses the information recorded for transferring, eating or toileting to make a recommendation regarding the applicant's or member's need for the Personal Care 3 level. The recommendation is recorded on Form H1700-1, Individual Service Plan.

At the initial certification and each annual reassessment, the MCO must check Form H1700-1 to determine if the applicant or member who chooses to reside in an AL non-apartment setting is identified as meeting the Personal Care 3 level. If the provider nurse does not provide a recommendation for Personal Care 3 level, the MCO must contact the nurse to obtain a Personal Care 3 level. The MCO documents the nurse's recommendation in the case record. The MCO must inform the applicant or member that he or she meets the Personal Care 3 level, and ensure the applicant or member is aware of all facilities contracted to provide care at the Personal Care 3 level by presenting a choice list of AL facilities that specifically identifies the Personal Care 3 facilities. The MCO authorizes the Personal Care 3 reimbursement rate if the applicant or member meets the Personal Care 3 level and chooses to reside in a contracted Personal Care 3 facility.

Changes may occur in a STAR+PLUS HCBS program member's health during the individual service plan (ISP) year that may cause the member to require a greater level of care in an AL facility (ALF), or move to an AL setting from a community setting. The MCO must review the most current MN/LOC Assessment to determine the provider clinician's recommendation regarding the member's Personal Care 3 level and ensure the member is presented with a choice of ALFs that are contracted at the Personal Care 3 level to provide a higher level of care.

Designation of an ALF as a Personal Care 3 facility is determined in the contracting process. To qualify as a Personal Care 3 facility, the ALF must meet the following requirements:

  • be a personal care facility licensed for four to 16 beds in a non-apartment setting;
  • provide 60 percent or more of its STAR+PLUS HCBS program members with a single occupancy bedroom;
  • maintain a minimum staffing ratio of one direct care staff member for every four members during the day and evening shifts, and a minimum of one direct care staff member for every eight members during the night shift; and
  • at least 60 percent of the total members served each month must require a minimum of one-to-one staff assistance as evidenced by a value of three or greater in one or more of the ADLs of transferring, eating or toileting, as assessed on the MN/LOC Assessment.

7230 Other Services Available to Members

Revision 19-1; Effective June 3, 2019

Each of the following services are provided according to the needs of the member, as authorized on the individual service plan (ISP), as a STAR+PLUS Home and Community Based Services (HCBS) program service and not included in the assisted living (AL) daily rate. The managed care organization (MCO) makes referrals for the services and coordinates delivery.

Adaptive Aids and Medical Supplies — The STAR+PLUS HCBS program AL member is eligible to receive needed adaptive aids and medical supplies under the STAR+PLUS HCBS program. Adaptive aids and medical supplies are defined as medical equipment and supplies that include devices, controls or appliances specified in the plan of care (POC) that enable members to increase their abilities to perform activities of daily living (ADLs) or to perceive, control or communicate with the environment in which they live. Refer to 6410, List of Adaptive Aids and Medical Supplies, for a list of adaptive aids and supplies that can be purchased through the STAR+PLUS HCBS program.

Minor Home Modifications (MHMs) — Services that assess the need, arrange for and provide modifications, and/or improvements to a member's residence to enable the member to reside in the community and ensure safety, security and accessibility. Minor home modifications are limited to those modifications identified and approved by the MCO on the ISP and apply to Type A facilities only. (Refer to Title 40, Texas Administrative Code §92.3, Types of Assisted Living Facilities.)

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

Physical Therapy (PT) — Specialized techniques for the evaluation and treatment related to functions of the neuro-musculo-skeletal systems. PT services consist of the full range of activities provided by a licensed physical therapist or a licensed physical therapy assistant (PTA), under the direction of a licensed physical therapist and within the scope of 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 licensed speech and language pathologists under the scope of the pathologist's state licensure.

Nursing Services — Services provided by a licensed registered nurse (RN) or licensed vocational nurse (LVN) within the scope of state licensure. Nursing services can be brought into the personal care facility for the member. If the projected cost of the member's services exceeds the annual cost limit, the MCO meets with the member to discuss the options for care, such as other living arrangements in adult foster care (AFC) or Title XIX Day Activity and Health Services. The member's choice for service delivery is given first priority as long as the cost for the service does not exceed the annual cost limit. STAR+PLUS services are also explored by the MCO for the delivery of all waiver services.

The use of self-administered oxygen is allowed in a STAR+PLUS HCBS program assisted living facility (ALF). Since oxygen is a flammable substance, precautions must be taken to ensure that smoking is prohibited in or around the area where the oxygen is being self-administered.

7240 Room and Board and Copayment Requirements

Revision 18-2; Effective September 3, 2018

The member must pay the required fees to be eligible for assisted living (AL) services. Refusal to pay the required fees can result in termination of services.

The facility must designate a due date for copayment and room and board in writing. The due date must be during the same month the copayment and room and board is applied. The facility must collect the entire copayment and room and board on or before the due date. If the due date falls on a weekend or a holiday, the facility must collect the entire copayment and room and board on or before the first business day thereafter.

7241 Room and Board Requirements

Revision 19-1; Effective June 3, 2019

All members must pay the room and board charges to be eligible for assisted living (AL). Room and board cannot be waived, but an assisted living facility (ALF) may choose to accept an applicant or member for a lower amount. STAR+PLUS Home and Community Based Services (HCBS) program policy does not direct the facility to accept or reject the applicant or member. The room and board charge is based on the Supplemental Security Income (SSI) federal benefit rate (FBR), minus a personal needs allowance of $85. This is a set rate unless there is a change in the FBR. Generally, the FBR only changes annually on January 1. The room and board charge is adjusted accordingly based on that change. For the initial month of entry, the monthly rate is divided by the number of days in that month, then multiplied by the number of days the member is in the ALF. The managed care organization (MCO) must notify the applicant or member of the initial amount of room and board to pay and the ongoing amount of room and board to pay.

7241.1 Copayment Requirements

Revision 23-2; Effective June 30, 2023

The amount of copayment the member is required to pay is determined by Medicaid for the Elderly and People with Disabilities (MEPD) specialists through use of the MEPD copayment worksheet. MEPD specialists make the determination of the amount available. The managed care organization (MCO) communicates the amount of copayment each member is to pay the provider.

Program Support Unit (PSU) staff mail Form H2065-D, Notification of Managed Care Program Services, to the member and upload a copy of Form H2065-D to MCOHub. Once received through MCOHub, the MCO sends a copy to the assisted living facility (ALF), detailing the first month's copayment amount and the subsequent months' amounts.

7242 Personal Leave

Revision 18-2; Effective September 3, 2018

The member is entitled to 14 days of personal leave from the assisted living facility (ALF) each year. The member is responsible for the room and board charge and copayment for personal leave days.

A day of personal leave is defined as 24 continuous hours. STAR+PLUS Home and Community Based Services (HCBS) program assisted living (AL) members must sign out when leaving the facility and sign in upon returning. The sign-in log must have at minimum the following information:

  • name of the person;
  • time and date of departure;
  • destination;
  • emergency contact; and
  • type of leave (for example, personal leave or hospital leave).

7243 Nursing Services for AL Members

Revision 19-1; Effective June 3, 2019

If a member is residing in an assisted living facility (ALF), all of the administration of medications, including injections, are provided by the nurse. It is possible that a member residing in an ALF does not need any nursing tasks that are to be delivered by the STAR+PLUS Home and Community Based Services (HCBS) program. Examples of when this may occur include when the member's only nursing need is for medication administration that is provided by the nurse or when the member is receiving nursing services through Medicare.

7244 Response to AL Member Condition Change

Revision 19-1; Effective June 3, 2019

If the member experiences a change in health or conditions related to the amount and type of care the member requires, the managed care organization (MCO), in conjunction with the other members of the interdisciplinary team (IDT), the provider, and the member or authorized representative (AR) may explore other means to serve the member adequately in his or her current setting. The use of day activity and health services (DAHS) for daily nursing tasks or the direct provision of nursing by provider nurses may be explored as alternatives that would avoid disrupting the member's living arrangement. Nursing tasks cannot be delegated in assisted living facility (ALF) settings.

If a member exhibits behavior or degradation of mental health that threatens the health or safety of himself or herself or others, or the member's needs exceed the licensed capacity of the facility, the AL provider must take appropriate action and notify the MCO orally by the next business day. The provider must confirm the verbal report in writing within seven days. The MCO must take appropriate actions based on the oral notification to assess the member's continued eligibility for the STAR+PLUS Home and Community Based Services (HCBS) program. Refer to 7251, Facility Reporting and Notification Requirements.

If a STAR+PLUS HCBS program member living in an assisted living (AL) apartment becomes a safety hazard to the member or others due to the member's operation of the stove or cooking unit in the apartment, the AL provider can disconnect the unit and must notify the MCO by the next business day. The MCO must investigate the situation and document any recent or previous incident which indicates a threat to the health or safety of the member or others. The MCO, in cooperation with the IDT, the AL provider, and the member's family or AR, if any, makes a decision regarding reconnection or continued disconnection of the cooking unit. The decision is documented on Form H2067-MC, Managed Care Programs Communication, which is sent to the AL provider within three business days of the IDT meeting.

7245 Hospital and Nursing Facility Stays

Revision 19-1; Effective June 3, 2019

Hospital Stays

To reserve bed hold during hospital stays, the member must pay the daily room and board charge.

The facility's bed hold charge or the negotiated bed hold charge for reserving a member's space during hospital stays may not exceed the maximum amount established by the managed care organization (MCO).

The facility does not bill the MCO for days the member is hospitalized. The member's room and board charge, used as a bed hold charge, constitutes the entire payment to the facility when a member is hospitalized.

The facility must notify the MCO via Form H2067-MC, Managed Care Programs Communication, when the member has been in the hospital for 30 days. The MCO monitors the member's situation every month up to four months to determine if the stay will become permanent. If the member stays in the hospital longer than four months, the member is systemically disenrolled. The MCO must notify PSU via Form H2067-MC.

A hospital includes a rehabilitation hospital or a rehabilitation floor or wing of a medical hospital.

Nursing Facility Stays

For issues related to nursing facility (NF) payment, see the Medicaid for the Elderly and People with Disabilities Handbook, H-1700, Deduction for Home Maintenance.

The MCO must follow the Uniform Managed Care Contract (UMCC), Attachment B.1, Section 8.3.2.6, Nursing Facilities, related to NF stays.

7246 Termination Due to Failure to Pay the Required Contribution to the Cost of Care

Revision 23-2; Effective June 30, 2023

If the member or authorized representative (AR) fails to pay the entire copayment and room and board by the facility's due date, the facility must notify the member or AR and the managed care organization (MCO) in writing that payment was not received. The facility must make an oral notification no later than the first business day after the due date. The facility follows up in writing within five days of when the member or the AR fails to pay the required payments.

Upon receipt of the written notice, the MCO:

  • coordinates with the facility to convene a meeting of the interdisciplinary team (IDT) within five business days of receipt of the written notification. The IDT must include the member, a facility representative, the MCO and the AR, if applicable;
  • explores with the member and IDT if there are new circumstances preventing the member from making the required payment. Circumstances to consider are:
    • the member has a situation involving a mandatory recoupment or other changes in income requiring an adjustment in countable income;
    • circumstances indicate that the member is being exploited by another person; and
    • other situations exist in which the member and facility can work out an agreement for the member to pay the required payments;
  • makes every effort to resolve the problem with the member and the facility;
  • advises the member of the consequences that result from refusal to make the required payments to the assisted living facility (ALF), including:
    • termination of eligibility;
    • eviction; and
    • being placed at the end of the interest list if the member reapplies for services in the future; and
  • asks the member to read and sign Form 2119, Residential Care or Assisted Living Contribution Acknowledgement, if the situation cannot be resolved and the member continues to refuse to pay the required payments. The form states that the member refuses to pay the required payments and understands the consequences of not meeting this eligibility requirement. If the member refuses to sign, the MCO documents the refusal on Form 2119 and has a witness sign. The MCO leaves the member a copy of Form 2119 and retains the original copy with the signature in the member's case record. The MCO advises the member that he or she will receive a notice to terminate services. The MCO also advises the member that he or she will not be allowed to move to another ALF while the member has an outstanding balance at the current ALF, and the current ALF may evict the member for refusal to pay.

After the IDT meeting, the MCO must:

  • make any appropriate referrals to adjust countable income;
  • refer to Adult Protective Services (APS), if exploitation is suspected; or
  • coordinate the notice of termination with the facility and Program Support Unit (PSU) staff by sending Form H2067-MC, Managed Care Programs Communication, within five days of the IDT meeting.

If the situation cannot be resolved and the member refuses to pay for any reason, within three business days of the MCO's notification, PSU staff:

  • mail the member Form H2065-D giving the member notice that services will be terminated effective the end of the month following the end of the 30 day notification period, as indicated on Form H2065-D unless the member pays the required payments. In the comments section of Form H2067-MC, PSU staff advise the member that services will end and the facility may evict the member if payment is not made by date indicated on Form H2065-D;
  • send the facility a copy of Form H2065-D;
  • fax a copy of Form H2065-D to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist;
  • upload a copy of Form H2065-D to MCOHub in the MCO's SPW folder, using the appropriate naming convention and a copy of Form H2065-D, following the instructions in 5110, MCOHub Naming Convention and File Maintenance; and
  • email a copy of Form H2065-D to the ERS mailbox for MAO members.

If the member does not appeal:

  • the facility may initiate eviction proceedings by giving the member an eviction notice in writing stating eviction will be effective the date indicated on the Form H2065-D.
  • and the member has not made other living arrangements by the denial date, the facility makes a referral to APS.
  • and the facility is in compliance with the provisions of its license and contract regarding the eviction of members, the facility evicts the member on the date provided on the written eviction notice.

If the member does appeal by the effective date of the action on Form H2065-D, PSU staff notify the MCO by uploading a copy of Form H2065-D to MCOHub in the MCO’s SPW folder. The member may receive other services, but remains ineligible for assisted living (AL) until all outstanding payments are made.

7250 Standards for Operation

Revision 23-2; Effective June 30, 2023

Assisted living facilities (ALFs) must:

  • provide each member the choice of a private or semi-private room;
  • reserve space for up to three days from the agreed-upon entry date for each referred member before requesting another referral;
  • designate a separate bedroom area for members in dual facilities where nursing facility (NF) members are co-housed in the facility; and
  • accept all managed care organization (MCO) referrals if space is available.

The only reason a STAR+PLUS Home and Community Based Services (HCBS) program assisted living (AL) provider could refuse to accept a referral is if the member's condition makes the member inappropriate for the facility according to the facility's personal care licensure.

Having a communicable disease does not necessarily make a member inappropriate for placement in an AL setting. Transmission of communicable diseases and conditions can be prevented through the implementation of infection control procedures, including universal precautions. Licensure standards for personal care facilities require facilities to have Infection Control Policy and Procedures, including universal precautions, in operation to safeguard employees and residents from these and other diseases, and contagious conditions. If transmission of the condition or disease cannot be controlled, the member cannot be placed in a STAR+PLUS HCBS program AL setting.

To receive AL services under the STAR+PLUS HCBS program, the applicant must first be determined eligible for the STAR+PLUS HCBS program. Program Support Unit (PSU) staff coordinate with Medicaid for the Elderly and People with Disabilities (MEPD) specialists, where applicable, to complete the Medicaid eligibility determination.

The MCO discusses residential options with the member, allowing the member to choose his or her preference. If an ALF is chosen, a verbal referral is made to the provider as an alert that space is needed. The starting date for services is a negotiated date between the MCO, the member and the AL provider. The initial copayment amount is computed based on the starting date. Form H1700-1, Individual Service Plan, and applicable attachments are sent as follow-up, along with a copy of Form H2065-D, Notification of Managed Care Program Services, which authorizes the provider to deliver STAR+PLUS HCBS program services, and Form H2067-MC, Managed Care Programs Communication, confirming the negotiated service initiation date.

Note: Appropriate action must be taken if the facility finds that a member threatens the health and safety of himself or herself or others. If a stove or cooking unit needs to be disconnected, the MCO service coordinator, in cooperation with the interdisciplinary team (IDT), makes this decision. The IDT must also include the MCO, the AL provider and the member's family or authorized representative (AR), if any.

The AL provider can disconnect the stove or cooking unit if the member exhibits a behavior that threatens the health and safety of him or her or others. The ALF must inform the MCO service coordinator of the disconnection by the next business day after it occurs. The MCO investigates the situation and documents any recent or previous incidents that indicate a threat to the health or safety of the member or others. If the decision is made to approve a disconnection, the MCO service coordinator documents actions on Form H2067-MC that is sent to the AL provider within three days.

Note: The ALF must make oral notification no later than the first business day after the due date. Within five business days of the MCO receiving notification from the provider that the member has failed to pay the copayment or room and board, the MCO uploads Form H2067-MC to MCOhub in the MCO's SPW folder using the appropriate naming convention. Form H2067-MC serves as notification to PSU staff of the member's failure to pay the copayment or room and board. Within three business days, PSU staff must send the member Form H2065-D stating services will be terminated if the member fails to pay the copayment and or room and board within 30 days of the date on Form H2065-D.

If a STAR+PLUS HCBS program member does not pay his or her copayment and/or room and board within 30 days of the date on Form H2065-D, the MCO contacts 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 10th day of the month) for the non-payment of the required fees, the member is still under obligation to pay the fees.

If the member simply refuses to pay the fees, or there is no legitimate reason for his or her failing to pay, the MCO writes a letter to the member, with copies to the facility manager and to the member's responsible party, if applicable, explaining the possible consequences of continued refusal to pay.

The MCO is responsible for working with the member during this time period to assure alternative services will be available. If the member refuses to leave the facility when his or her services are terminated, the facility must follow its written eviction procedures.

In addition, ALFs must:

  • conduct a health assessment with the member within three days of admission to the facility;
  • provide each member with training in the emergency or disaster procedures and evacuation plan within three days from the date of service initiation. The training must be documented in the member's record. The facility must also document all training and orientation provided to members and facility staff;
  • provide services according to the member's health assessment or individual service plan (ISP);
  • document the member's daily activity and service delivery on the daily census record;
  • obtain written approval from the MCO before discharging a member, except when MCO staff cannot be reached and the member threatens the health or safety of himself or herself or others;
  • help the member to prepare for transfer or discharge;
  • provide a minimum of four social and recreational activities per week;
  • collect payment from the member according to copayment and room and board policies. If payment is not made by the 10th day of the month, the facility must send notice to the member by the 11th day of the same month;
  • allow the member to manage his or her finances and/or trust funds. The facility must provide assistance to the member in managing his or her finances only if the member requests assistance in writing;
  • refund, within five business days after the member has been discharged, the full balance of the member's personal funds that the facility deposited in an account. This applies to copayments and trust funds; and
  • inform the member verbally and in writing, before or at the time of admission, of bed hold policies for hospital or nursing facility (NF) stays, personal leave, eviction procedures, all available services in the facility, and charges for services not paid by the MCO and/or not included in the facility's basic daily rate.

Examples of charges not paid by the MCO could be the destruction of facility property or any additional charges, such as pet deposits. Items not required to be provided by the AL provider through the ALF licensing standards (for example, returned check fees, service deposits) may be charged to the member if listed in the admission agreement. The MCO may contact Texas Health and Human Services Commission (HHSC) Regulatory Services Division regarding any questionable items charged to the member.

7251 Facility Reporting and Notification Requirements

Revision 19-1; Effective June 3, 2019

The facility must verbally report to the managed care organization (MCO) the following occurrences pertinent to member services by the next business day after they occur. These occurrences must be followed up in writing within five business days after they occur and may lead to MCO intervention and/or termination of services, including but not limited to:

  • significant changes in the member's health and/or condition, such as:
    • the member enters a hospital, nursing facility (NF), state school or state hospital;
    • death of a member; or
    • serious occurrences or emergencies involving the member or facility staff; and
  • changes based on member actions, such as the member:
    • is discharged because he or she threatens the health or safety of himself or herself or others;
    • leaves the state;
    • requests that services end;
    • refuses to comply with the individual service plan (ISP);
    • fails to pay the copayment;
    • exceeds personal leave days; and
    • requests to move to another facility.

If a member exhibits behavior that threatens the health or safety of himself or herself or others, or the member’s needs exceed the licensed capability of the facility, the provider's written notice must explain the situation and the reasons the member is no longer appropriate for the services. With the concurrence of the MCO, discharge can be as soon as practical when:

  • the health or safety of individuals in the facility would be endangered if the member would remain in the facility; or
  • the member's medical needs escalate beyond the capability of the facility to meet the member's needs. For example, the member's mental condition may deteriorate to the point that involuntary commitment to a mental institution is necessary.

7252 Member Documentation

Revision 18-2; Effective September 3, 2018

The facility must maintain records for each member that include at least the following information:

  • health assessment;
  • serious occurrences or emergencies involving members or facility staff;
  • incidents when a member threatens the health or safety of himself or herself or other residents in the facility;
  • documentation when the member has used 10 personal leave days during the member's current individual service plan effective period;
  • documentation when the member's needs exceed the licensed capability of the personal care facility;
  • termination of services to a member;
  • hospitalization of a member;
  • death of a member; and
  • documentation when a member requests to move to another facility.

7260 Staffing and Training Requirements

Revision 18-2; Effective September 3, 2018

The facility must provide all staff with training in the fire, disaster and evacuation procedures within three business days of employment. The training must be documented in the facility records.

7270 Copayment and Trust Fund Records

Revision 18-2; Effective September 3, 2018

 

7271 Copayment

Revision 11-3; Effective September 1, 2011

The facility must keep receipts for all copayments collected. The facility must deduct the copayment amount as documented on Form H2065-D, Notification of Managed Care Program Services.

The facility must maintain a current member copayment ledger system that reflects all charges and all payments made by or on behalf of each member. This system must reflect all copayment charges, payments and balances; it must be maintained in accordance with generally accepted accounting principles. If a member copayment is paid from a trust fund, the facility still must prepare a receipt.

The ledger must also reflect room and board charges and payments, and the member must be given a receipt for the room and board payments.

7272 Trust Fund Records and Written Receipts

Revision 19-1; Effective June 3, 2019

The facility must maintain trust fund records based on recognized fiscal and accounting principles, and have written permission from the member to handle his or her personal financial affairs.

Members must be informed that:

  • funds will be commingled with the funds of other members if the facility will handle the member's trust fund; and
  • the facility may review trust fund records of all members whose funds are commingled.

If the member is unable to sign or initial the transaction, or if the member signs his or her name with a mark (x), the transaction must be signed by a witness. The facility must:

  • keep the member's trust fund accounts separate from the facility's operating accounts. The separate account must be identified "Trustee, (name of facility), Member's Trust Fund Account";
  • make the member's trust records available for review by the facility during work hours without prior notice;
  • not charge the member for services that the facility is expected to provide for the member;
  • refrain from charging 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 facility is handling; and
  • include at least the following in the trust fund records:
    • member's name;
    • identification of member's representative payee or responsible party;
    • transactions; and
    • member's earned interest.

The facility may choose one of the following options:

  • 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 or her trust fund, the transaction or receipt must be signed by a witness or 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 must sign the transaction or receipt.

  • 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;
    • prorated to each member on the basis of his or her end-of-quarter balance; or
    • prorated to each member's account monthly if interest is paid on a monthly basis.

If the facility earns interest on any pooled interest account, the interest earned must be prorated to each member's account. Deposit entries should be documented as "interest" in the member's ledger. All transactions must be posted by the middle of the following month. The facility may:

  • keep a running balance; or
  • compute a balance at the end of the month.

If the facility maintains a trust fund, the facility staff must:

  • give the member a receipt for the money deposited into the trust fund;
  • 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 facility 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. If the member writes a check to be deposited into his or her trust fund account and there are insufficient funds to cover the check, the facility can charge the member only the actual insufficient funds fee charged by the bank.

There is no requirement that the deposit into the trust fund be made on the same date the money is received. However, the facility must ensure that the deposit slip/bank statement reflects the same amount recorded on the receipt.

7273 Records and Receipts

Revision 18-2; Effective September 3, 2018

The facility must ensure that records include written receipts for all purchases made by or for members. A receipt is a written or computer-generated, signed record of payment prepared at the time of payment. If the payment is in person, the written or computer-generated receipt must be signed and contemporaneous with the payment. If the payment is by mail, a statement at the end of the month satisfies the requirement for a written receipt and a bill for the next month. If a single receipt is written for different items, the receipt must clearly describe what the receipt covers.

The record or receipt must include the:

  • name of member;
  • date the money was received;
  • coverage period;
  • purpose of payment;
  • amount received;
  • source of the money;
  • amount returned, if any; and
  • signature of the facility representative.

The facility is required to have both a trust fund ledger and a copayment ledger. A current member copayment ledger system must be maintained that reflects all charges and all payments made by or on behalf of each member. This system must reflect all copayment charges, payments and balances, and be maintained in accordance with generally accepted accounting principles.

The facility must maintain both receipts for monies received from members and bank deposit slips showing the money deposited. These amounts must correspond to amounts recorded in the member's trust fund ledger. This system must be maintained in accordance with generally accepted accounting principles.

Vendor withdrawal records must be maintained, regardless of how facility staff account for trust fund transactions (withdrawals on a ledger, cash envelope or individual checkbook register). They must retain receipts for any payment out of a trust fund account that is more than $1.00. The receipt, cash register tape or sales statement is documentation of who actually received the money that was withdrawn from the trust fund account, and that the money was spent as authorized. Any unused money returned to the trust fund custodian must be redeposited to the member's trust fund account and appropriately documented. The prerequisites that allow withdrawal from the member's trust fund are:

  • the purchase must be authorized by and for the benefit of the member;
  • the cost must be reasonable; and
  • facility staff do not profit from the transaction. For example, purchasing items in bulk and selling them at a higher price; or the member authorized the purchase of a TV, stereo, refrigerator, and staff are using it.

7274 Vendor Receipts

Revision 11-3; Effective September 1, 2011

The following information must be included on all trust fund vendor receipts (other than long-term payments):

  • name of the member;
  • date the receipt was written;
  • store name;
  • amount of money spent or received; and
  • item purchased.

7275 Group Purchases

Revision 18-2; Effective September 3, 2018

Often, a single purchase is made for goods to be distributed among specific members (for example, cigarettes). In such a case, the invoice or receipt should show the:

  • names of the members for whom the purchase was made; and
  • portion of the total price charged to each individual account.

Group purchases are only allowable if they can be traced to the member.

7276 Payment of Copayment and Room and Board from Trust Fund

Revision 18-2; Effective September 3, 2018

It is an acceptable and recommended practice to deposit the member's income into the trust fund account and then pay the copayment and room and board from the trust fund account. In this way, the member's monthly payments can be traced to the trust fund. When the copayment and room and board is paid from the trust fund account, the corresponding member's account receivable ledger must show proper credit to the member's account.

Long-term Payments

For long-term payments, facility staff must obtain a signed statement from the member or responsible party authorizing long-term payments on the member's behalf. Examples of long-term payments include insurance premiums, church tithe and cable TV. If the facility:

  • has a signed statement from the member authorizing the facility to pay long-term payments on the member's behalf, they do not need a monthly receipt from the vendor; or
  • does not obtain a signed statement from the member or authorized representative (AR) authorizing it to pay the monthly payment on the member's behalf, the facility must have a vendor receipt that includes all items previously identified.

Daily Withdrawals for Minor Purchases or Petty Cash Withdrawals

Members usually require small amounts of money to meet their daily needs for items such as soft drinks, snacks, etc. It is often difficult to keep supporting documents for all such minor purchases.

The member's signature or authorization for a cash withdrawal must be on the individual member ledger, the cash envelope or on a receipt.

Bulk Purchases

Bulk purchase of the same items may be made by the facility. In this case, the member's signature and the amount of the purchase must be on the member ledger or a receipt.

7277 Member Authorization

Revision 18-2; Effective September 3, 2018

If the member is unable to sign or initial the transaction, or if the member signs his or her name with a mark (X), the transaction must be signed by a witness. A witness is anyone other than the:

  • facility employee who is responsible for managing the trust fund accounts;
  • supervisor of the employee who manages the trust fund account; or
  • person who is receiving payment for services to the member.

7278 Refunds to Discharged or Deceased Members

Revision 18-2; Effective September 3, 2018

The facility must refund the full balance of the member's monies deposited in his or her trust fund account within five days after the member is discharged. If the member dies, there should be no payment from his or her trust fund account other than the refund to the responsible party. No funds may be dispensed to reimburse the facility for damages caused by the member to an assisted living (AL) apartment. If there is a responsible party, the facility may request voluntary reimbursement prior to the refund, but the responsible party is not obligated to agree.

Maintenance to the facility is included in the cost report as an allowance expense.

The two types of refunds are listed below:

Check — If the refund was made by check, the cancelled check or a copy of the receipt must be signed by the member or responsible party.

Cash — If the refund was made by cash, the receipt must be signed by the member or responsible party.