Form 1045, Request for Extension of Enrollment Offer Due Date

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Documents

Effective Date: 10/2024

Instructions

Updated: 10/2024

Purpose

The local intellectual and developmental disability authority (LIDDA) uses Form 1045 to request the Texas Health and Human Services Commission (HHSC) extend the LIDDA’s due date for completing a Home and Community-based Services (HCS) or Texas Home Living (TxHmL) program enrollment offer.

Procedure

The LIDDA receives written notice from HHSC when the LIDDA must offer HCS or TxHmL enrollment to a person. The LIDDA must complete the enrollment offer process by the due date in the notice.

When to Prepare

The LIDDA must submit a request to extend the due date if the enrollment offer process will not be completed by the date in HHSC’s notice. HHSC will send written notice if it approves the extension. The LIDDA must submit another request if it is unable to complete the enrollment offer process by the extended date. Until the enrollment offer process is complete, the LIDDA must submit subsequent requests to HHSC before the approved extended due date.

HHSC considers the enrollment process to be complete when the person’s enrollment has been processed by HHSC. The person's Community Services Interest List (CSIL) record for the program is closed with the applicable closure reason.

Submittal

A completed Form 1045 must be submitted in separate attachments for each person. The LIDDA must name each completed Form 1045 with the following file naming convention:

  • the person’s last name;
  • the person’s first name;
  • slot type number;
  • ext; and
  • date of the extension request.

Example: SmithBob114ext10-05-2021

Note: Multiple extensions sent in one PDF will be returned unprocessed.

The LIDDA emails the completed form to LiddaRequests@hhs.texas.gov using a secure email method. To make sure the form is assigned appropriately, the LIDDA must include the slot type and slot number in the subject line. Do not put other numbers in the subject line.

Example: Slot #134 AOC Extension Request

If the LIDDA does not have access to a secure email method, it emails HHSC at LiddaRequests@hhs.texas.gov to request a secure email. The LIDDA can reply to a secure email from HHSC to submit the form.

Detailed Instructions

Today’s Date — Select the date the form is submitted to HHSC from the drop-down calendar.

Section 1, LIDDA Information

LIDDA Name — Enter the LIDDA's name.

LIDDA Comp Code — Enter the LIDDA's component code.

Program — Select HCS or TxHmL to indicated the program offered.

Slot Type No. — Enter the slot type number. Refer to the notice from HHSC.

Name of Person Completing Form — Enter the name of the person completing the form.

Area Code and Phone No.  — Enter the area code and phone number of the person completing the form.

Email — Enter the email address for the person completing the form.

Date LIDDA Notified Person or LAR — Select the date from the LIDDA’s enrollment offer letter sent to the person or legally authorized representative (LAR) from the drop-down calendar.

Note: If the enrollment offer was received by transfer from another LIDDA, enter the next three fields.

Date County of Residence Changed if transferred — Select the date the LIDDA completed the county change in the CSIL application from the drop-down calendar.

Transferring LIDDA Comp Code  Enter the comp code of the LIDDA transferring the enrollment offer.

Receiving LIDDA Comp Code — Enter the comp code of the LIDDA receiving the enrollment offer.

Section 2, Person's Information

Name — Enter the first and last name of the person who received the slot offer.

Client Assignment and Registration (CARE) ID — Enter the person’s CARE ID number.

Note: Check CARE screen C63, Medicaid Eligibility Search, to enter the information in the fields below.

Is Medicaid Active?  Select Yes if the person’s Medicaid is active and enter the Medicaid Effective Date as shown in CARE C63, Medicaid Eligibility Search. Select No if no results are shown in CARE C63 and enter the date an application for Medicaid or Supplemental Security Income (SSI) was submitted. If an application has not been submitted, document the reason for the delay in Section 4.

Medicaid Number — Enter the person’s Medicaid number as shown in CARE C63, Medicaid Eligibility Search. Enter none if No was selected for Is Medicaid Active? question.

Medicaid Type — Enter the person’s Medicaid coverage code and program type as shown in CARE C63, Medicaid Eligibility Search. Enter none if No was selected for Is Medicaid Active? question.

Current Living Situation — Select the appropriate response from the drop-down menu to indicate where the person currently resides. Do not leave this field blank. If Other is selected from the drop-down menu, describe the current living situation in the Current Living Situation Comments.

Projected Facility Discharge Date — If the person resides in a facility, enter the projected facility discharge date. Do not leave this field blank.

Current Living Situation Comments — If Other is selected in Current Living Situation, describe the current living situation here and any other current living situation barriers to the enrollment progressing. The field will expand as needed.

Current Services Received through a Mutually Exclusive Program — Select the appropriate response from the drop-down menu to indicate if mutually exclusive services are being received. Refer to LIDDA Handbook Appendix I, Mutually Exclusive Services. Do not leave this field blank. If Other is selected from the drop-down menu, enter the program or service in Section 4.

Projected Program Discharge Date — If mutually exclusive services are being received enter the projected discharge date for services from the drop-down calendar. If the date is unknown, document the reason for delay in Section 4.

If any Mutually Exclusive Programs have been selected, has the LIDDA coordinated the program discharge? — Select Yes, No or Not applicable.  Note: To avoid service interruption, the service coordinator must contact the case manager of the other program to coordinate begin and end dates. Refer to the LIDDA Handbook.

Section 3, Enrollment Activities — For each enrollment activity, select Yes or No to indicate activity completion. If No is selected for any activity, give a detailed explanation including dates in the appropriate box. The fields will expand as needed.

Submitted

HCS or TxHmL Pre-Enrollment form — Select Yes or No to indicate if it has been entered in the Long-Term Care Online Portal. If No, thoroughly document the reason for the delay and the barriers to completion in the appropriate Detailed Explanation box.

Form 8578, Intellectual Disability/Related Condition (IDRC) — Select Yes or No to indicate if it has been entered in the Long-Term Care Online Portal. If No, thoroughly document the reason for the delay and the barriers to completion in the appropriate Detailed Explanation box.

Form 3608 or 8582, Individual Plan of Care (IPC) — Select Yes or No to indicate if it has been entered in the Long-Term Care Online Portal. If No, thoroughly document the reason for the delay and the barriers to completion in the appropriate Detailed Explanation box.

Signed and Uploaded in LTC Online Portal

Form 8601, Verification of Freedom of Choice (VFC) — Select Yes or No to indicate if it has been signed by the person or LAR and uploaded in the Long-Term Care Online Portal. If No, thoroughly document the reason for the delay and barriers to completion in the appropriate Detailed Explanation box.

Completed

Determination of Intellectual Disability (DID) Completed  Select Yes or No to indicate if a DID has been completed. If Yes, enter the date the DID was completed. If No, thoroughly document the reason for the delay and the barriers to completion in the appropriate Detailed Explanation box.

Provider Choice  Select Yes or No to indicate if a provider has been chosen. If Yes, enter the date of the choice from the drop-down calendar and enter the provider comp code. If No, thoroughly document the reason for the delay and the barriers to completion in the appropriate Detailed Explanation box.

Note: The following signed and completed forms must be attached to the Pre-Enrollment form in the LTC Online Portal:

  • Form 1049, Initial Documentation of Provider Choice; and
  • Form 8001, Medicaid Estate Recovery Program Receipt Acknowledgement.

Enrollment IPC Meeting — Select Yes or No to indicate if the Enrollment IPC Meeting has occurred. If Yes, enter the date the meeting was held from the drop-down calendar. If No, thoroughly document the reason for the delay and the barriers to completion in the appropriate Detailed Explanation box.

Section 4, Additional Information Related to Delay of Enrollment or Timelines — Add more details related to the delay or barriers to the person’s enrollment that have not been addressed above. Also list the actions the LIDDA has taken to resolve the delays. Timelines are encouraged in this area to show movement in the enrollment process. The field will expand as needed.