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Revision 19-1; Effective June 3, 2019
Respite care services in the STAR+PLUS Home and Community Based Services (HCBS) program are available on an emergency or short-term basis to relieve those persons normally providing unpaid care for a STAR+PLUS HCBS program member unable to care for himself or herself.
7310 Service Coordination Duties Related to Respite Care
Revision 21-2; Effective August 1, 2021
To be eligible for respite care services, the member must live in his or her own home or with relatives or other individuals. The member may not live in an adult foster care (AFC) or assisted living (AL) setting.
The respite care provider must not be a primary caregiver, whether or not the respite care provider is related to the member, and must not live with the STAR+PLUS Home and Community Based Services (HCBS) program member for whom respite care is needed. If the member's primary caregiver is the paid attendant who also provides uncompensated care, in-home respite care may be provided only during those hours the primary caregiver would be providing uncompensated care to the member. If the primary caregiver is the paid attendant and will be absent during hours for which the primary caregiver is normally paid, it is the employer of record who has the obligation to provide a substitute attendant during this period.
Respite care services is intended to relieve the primary caregiver during emergency or planned short-term periods. Respite care services must be authorized on the individual service plan (ISP) before it can be delivered. The respite care rate for out-of-home settings includes payment for room and board. There are no member copayment or room and board charges for respite care in out-of-home settings.
The managed care organization (MCO) service coordinator is responsible for documenting the respite care services needed by the member. For example, a member needs respite care every Friday afternoon so the primary caregiver can attend class, or a member's primary caregiver has three four-day trips planned during the ISP year, or a caregiver has a history of emergency hospitalizations. The MCO service coordinator's documentation must also support that the member meets the eligibility criteria for respite care. The MCO service coordinator should provide supporting documentation regarding the number of hours requested or authorized when the 30-day maximum is requested or authorized. Respite care cannot be authorized retroactively. For STAR+PLUS HCBS program members who have an emergency need for respite care and respite care is not authorized on the ISP, the provider must contact the MCO for authorization prior to delivery of respite care services.
The member must be given the opportunity to choose from the contracted providers that are appropriate considering the member's needs and the licensed capabilities of the provider. In-home respite care is provided by licensed providers contracting with the MCO and/or a Home and Community Support Services Agency (HCSSA) that is contracted with the MCO to provide services. Out-of-home respite care is provided by licensed nursing facilities, licensed personal care facilities and licensed AFC homes.
The provider who delivers in-home respite care is responsible for providing the personal assistance services authorized on the ISP, with the possible exception of delegated nursing tasks. When a member is receiving in-home respite care and the attendant providing the personal care is not the same attendant to whom the nursing tasks were delegated, the nurse may directly provide the nursing care. It is necessary for the MCO to modify the ISP to include the increased direct nursing based on information provided by the provider. Other services (for example, physical therapy or minor home modifications) may continue to be delivered at the same time as the in-home respite care.
Respite care services must be authorized on Form H1700-1, Individual Service Plan. Respite care services can be authorized as often as needed for primary caregiver relief or emergency absences of the primary caregiver up to the 30-day maximum per ISP year, within the limit of the member's cost limit. For example, if two hours of respite care are to be used per week, the ISP authorization is for eight 15-minute units. The calculation is two hours per week times 52 weeks = 104 hours multiplied by four 15-minute units. The annual limit on respite care services is 30 days, equivalent to 720 hours which equals 2,880 units (30 days times 24 hours per day; 720 hours = 2880 15-minute increments), unless approval to exceed the 30-day limit is given by the MCO. The MCO, who has overall responsibility for the coordination of STAR+PLUS HCBS program services, must keep track of the units a member has used. The provider may use Form H2067-MC, Managed Care Programs Communication, to notify the MCO of the dates and duration of respite care services delivered. The MCO can track the number of respite care days used.
7311 MCO Approval to Exceed the Respite Service Cap
Revision 19-1; Effective June 3, 2019
To request approval to exceed the annual individual service plan (ISP) 30-day limit on respite care services, the provider must send a written request to the managed care organization (MCO) documenting the:
- need for additional respite care units;
- number of additional units needed;
- cost estimate considering the location(s) in which the respite care services will be delivered;
- overall service plan is within the member's ISP cost limit; and
- ISP is adequate and meets the individual's needs in the community.
The provider includes his or her telephone number and address in the written request. The MCO provides written approval or disapproval of the request. In reviewing requests to exceed the respite care services limit, the MCO must consider the intent of respite care services to relieve the caregiver during emergency or planned short-term periods. Approval to exceed the 30-day maximum should be related to situations such as:
- members whose primary caregivers become ill, hospitalized or have a family emergency;
- extenuating circumstances that cause care to be required beyond routine or periodic respite care relief; or
- a breakdown in member or family support, causing an increased risk of institutionalization because of the physical burden and emotional stress of providing continuous support and care to a dependent person.
7320 In-Home Respite Care
Revision 21-2; Effective August 1, 2021
In-home respite care offers services provided by managed care organization (MCO) contracted providers, on a short-term basis, to members unable to care for themselves because of the absence or need of relief for their unpaid primary caregiver.
In-home respite care is provided in the member's own home, as authorized on the member's Form H1700-1, Individual Service Plan, when the unpaid primary caregiver needs relief. The provider is responsible for providing the tasks authorized on the member's ISP and Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, and Form H2060-A, Addendum to Form H2060, during the time the member is receiving in-home respite care.
The provider must document in the member's clinical record:
- the in-home respite care services provider was given a briefing on the member's status, needs and preferences prior to delivering services; and
- dates and duration of the services delivered.
In-home respite care services helps prevent member and/or family support breakdown and the consequent institutionalization, which may result from the physical burden and emotional stress of providing continuous support and care to a dependent person.
The in-home respite care services provider must deliver the personal assistance services (PAS). The MCO may allow the in-home respite care services provider's registered nurse (RN) the option of either directly providing any needed nursing services or delegating the nursing task(s) to the in-home respite care services provider.
In-home respite care services is not intended to be used when the primary caregiver needs to be out of the house for short periods of time (for example, to go to the pharmacy or grocery store to pick up medications or grocery items). The primary caregiver should be encouraged to be out of the house for brief respite care when the attendant is providing the PAS.
7330 Out-of-Home Respite Services
Revision 19-1; Effective June 3, 2019
Out-of-home respite care services provide a 24-hour living arrangement in an adult foster care (AFC) home, a licensed personal care facility or a licensed nursing facility (NF) for persons who, because of the unavailability of their primary caregiver, have no one to meet their needs on a short-term basis. Services may include meal preparation, housekeeping, personal care and nursing tasks, help with activities of daily living (ADLs), supervision, and the provision or arrangement of transportation.
Nursing tasks may be directly provided by licensed nurses in out-of-home respite care services or may be delegated as determined by the professional judgment of the provider's registered nurse (RN), unless facility licensure prohibits delegation.
7331 Member Eligibility
Revision 19-1; Effective June 3, 2019
The respite care services member must:
- meet all eligibility criteria, as specified in 3200, Eligibility;
- reside in his or her own home;
- have a primary caregiver who needs relief either on an emergency or planned short-term basis; and
- not reside in adult foster care (AFC) or a personal care facility.
The applicant for STAR+PLUS Home and Community Based Services (HCBS) program respite care services must complete the same eligibility determination process as other STAR+PLUS HCBS program members.
7332 Provider Qualifications
Revision 19-1; Effective June 3, 2019
Out-of-home respite care services providers must be a:
- licensed nursing facility (NF);
- licensed personal care facility; or
- Texas Health and Human Services Commission (HHSC) licensed adult foster care (AFC) home.
In order to deliver STAR+PLUS Home and Community Based Services (HCBS) program out-of-home respite care services, the provider must complete and sign a contract with the managed care organization (MCO). The contract must be signed by both the provider and MCO prior to the provider serving members.
7333 Description of Services
Revision 19-1; Effective June 3, 2019
The STAR+PLUS Home and Community Based Services (HCBS) program member may receive out-of-home respite care services in a nursing facility (NF), a personal care facility or a Texas Health and Human Services Commission (HHSC) licensed adult foster care (AFC) home, with services to be delivered as authorized on the individual service plan (ISP) and in accordance with facility licensure and contract requirements. The STAR+PLUS HCBS program member may take any adaptive aids he or she is using to the out-of-home respite care setting.
The managed care organization (MCO) provides the out-of-home respite care provider with the assessments and ISP attachments pertinent to the services the member will receive while in the facility or home. The provider must deliver services as identified on the member's ISP attachments.
7334 Respite Care Services in a Personal Care Facility or AFC Home
Revision 19-1; Effective June 3, 2019
The STAR+PLUS Home and Community Based Services (HCBS) program member receiving respite care services in a personal care facility or adult foster care (AFC) home may receive nursing services or therapy services from outside providers while residing in the respite care setting. The need for any service must be authorized on the individual service plan (ISP) before the member receives the service.
The STAR+PLUS HCBS program member receiving respite care services in an AFC home must qualify for placement in the particular level of AFC home by meeting the specific criteria for that level of home.
Nursing services provided in a Level I or Level II AFC home may be delegated, according to the professional judgment of the provider's registered nurse (RN). Personal care facility licensure prohibits delegation of nursing tasks. In assisted living (AL) out-of-home respite care settings, nursing services must be provided directly by licensed nurses.
7335 Respite Care Services in a Nursing Facility
Revision 19-1; Effective June 3, 2019
The STAR+PLUS Home and Community Based Services (HCBS) program member receiving respite care services in a nursing facility (NF) may receive therapy services from outside providers. The member's need for any service must be authorized on the individual service plan (ISP) before receiving the service. The NF is responsible for providing the needed nursing services to the member.
7340 Room and Board
Revision 19-1; Effective June 3, 2019
Room and board charges are not allowable charges to the STAR+PLUS Home and Community Based Services (HCBS) program member receiving out-of-home respite care services. Room and board charges are included in the rates for the respite care services.