Form 2027, Home-Delivered Meals Waiver Request

Instructions for Opening a Form

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Documents

Effective Date: 7/2021

Instructions

Updated: 7/2021

Purpose

A provider of home-delivered meals (HDM) funded through Title XX completes Form 2027 to request a waiver of the Texas Health and Human Services Commission (HHSC).

Each provider requesting an HDM waiver will only submit one Form 2027. The form allows multiple waiver requests to be entered within the same form but the form must be completed electronically.

Providers may request waivers for one or more of the following:

  • To deliver meals less than five days a week.
  • To deliver a combination of hot, frozen and/or chilled meals.

The waiver must address:

  • pattern and type of meal delivery the provider is requesting,
  • service area or location affected,
  • the estimated number of individuals covered under the waiver,
  • shortest distance from the meal site to an individual served under the waiver, and
  • the circumstances necessitating the waiver request.

Providers with an approved HDM waiver must contact each individual included in the waiver by phone or in person at least three times per week.

The waiver is an amendment to the provider’s contract for federal fiscal years (FFY) 2022 and 2023 when the waiver request is submitted to and approved by HHSC.

An HHSC case manager must give authorization when an individual receiving meals through Title XX requires delivery of fewer than five meals a week. In those cases, the provider does not submit Form 2027.

Shelf-stables meals provided during emergency or inclement weather situations do not require waiver approval. Shelf-stable meals will not be an approved alternate meal.

Basis for a Waiver Request

Title XX

Texas Administrative Code (TAC), Title 40, Part 1, Chapter 55, §55.21
Frozen, Chilled, or Shelf-Stable Meals

A provider agency may use frozen, chilled, or shelf-stable meals for emergency or inclement weather situations, emergency situations, and for situations approved by the contract manager on a case-by-case basis, if the following conditions exist:

  1. Sanitary and safe conditions for storage, thawing, and preparation of the meal can be provided by the provider agency and the client.
  2. Meals can be safely handled by the client, or by another available person if the client is unable to do so.

Procedure

When to Prepare

Form 2027 decreases the number of HDM waiver requests completed by providers and allows multiple waiver requests to be included on one form. Using this form, the waiver is based on the meal delivery pattern rather than the waiver areas or location. Therefore, waiver areas or locations may be combined if the meal delivery pattern for one or more areas is identical. To add an additional meal delivery pattern for one or more areas, click on the “Add Waiver Request” button to insert another HDM waiver request. Add as many meal delivery patterns and waiver areas as needed.

Transmittal

The provider must complete the form in its entirety and submit it to HHSC. The waiver will be approved or denied and returned to the provider.

Detailed Instructions

Name of Legal Entity — Enter the legal entity’s name as it appears on the contract.

Signature Authority — Enter the name of the person who has signature authority for the legal entity.

Mailing Address, City, State, ZIP — Enter the provider's address as it appears on the contract.

HDM Waiver Request — Check the box to acknowledge each individual included in an approved HDM waiver must be contacted in person or by telephone at least three times per week.

Meal Delivery Pattern

Using the drop-down menu, select the number of hot, frozen and/or chilled meals delivered to individuals each week. — Select 0-7 to indicate the number of hot, frozen and/or chilled meals an individual will receive each week.

Waiver Area — Describe the city and county or the portions of the city and county that the waiver will cover. The waiver area box will expand so that multiple areas or locations may be added if the meal delivery pattern for each area is identical.

Alternate Meals

Estimated number of individuals who will receive alternate meals under this waiver each week — Enter the estimated number of individuals who will receive alternate meals on a modified delivery schedule.

Shortest distance (number of miles) from the meal preparation site to an individual served under this waiver. — Enter the number of driving miles from the meal preparation site to the individual.

Add Waiver Request – Click “Add Waiver Request” button to complete a request for another meal delivery pattern. Once selected, a new HDM waiver request will appear below the initial waiver request, and so on. Complete the HDM waiver request information for each area where the meal delivery pattern changes.

Select all circumstances necessitating this waiver. — Select one or more of the listed circumstances to indicate why the provider is requesting a waiver. If other was selected, explain the circumstances that make this waiver necessary.

Assurances

Signature – Signature Authority — The person who has signature authority for the provider must sign on this line or complete an electronic signature.

Date — Type or print clearly the date the person with signature authority for the provider signs the form.