Form 2812, Youth Empowerment Services (YES) Waiver Adaptive Aids & Supports (AA&S) Request

Instructions for Opening a Form

Some forms cannot be viewed in a web browser and must be opened in Adobe Reader on your desktop system. Click here for instructions on accessing your form.

Effective Date
2812.pdf (116.09 KB)



Updated: 7/2020



Adaptive Aids and Supports are one-time goods and services that have been identified as necessary to assist the participant to remain in the home and community and avoid an out-of-home placement. In accordance with Center for Medicare and Medicaid Services (CMS), adaptive aids must be medically necessary to treat, rehabilitate, prevent, or compensate for conditions related to the participant’s mental health condition(s).

All AA&S requests must be individualized, developed through the wraparound process with the Child and Family Team (CFT), and be connected to a strategy to assist the participant in meeting their treatment goals. During the monthly CFT, the Wraparound facilitator must document and show evidence that the AA&S is being utilized and monitored for efficacy.

Special Requirements

Some AA&S requests may require additional evidence of medical necessity to be approved.

Restrictive Interventions

Some adaptive aids may be considered a restrictive intervention. Examples of restrictive interventions include, but are not limited to:

  • door or window alarms added to a participant’s environment;
  • security cameras;
  • locked access;
  • restricted access to personal property.

When the request is considered a restrictive intervention, the Comprehensive Waiver Provider must inform the participant of their rights, including how to report abuse, neglect, and exploitation. The informed consent and explanation of rights must be included in the participant’s Crisis and Safety Plan and the Wraparound Plan of Care.


AA&S cannot be used to pay for services that are:

  • requested for recreational purposes;
  • provided in lieu of an available service in the YES service array;
  • goods and services that a household, which does not include a person with a disability, would be expected to pay for; and
  • goods or services for someone other than the participant.

AA&S and minor home modifications are limited to an annual maximum combined amount of $5,000 per participant.

For additional requirements, reference the YES Waiver Policy Manual.



When to Prepare

The Wraparound facilitator shall only complete this form in accordance with the wraparound process. Prior to submitting the AA&S request form, the AA&S should be discussed during the CFT meeting and documented in the Wraparound Plan.


If the AA&S is less than $500, complete Parts I and III. If the AA&S is more than $500, complete Parts I, II and III.

A separate AA&S request form must be submitted for each individual request. The submitted AA&S request form must be completed accurately. If the WPO does not complete all sections of the AA&S request form, it will be considered incomplete and will not be reviewed.

The YES Program Manager must submit the completed form to HHSC YES Waiver inbox at to be processed.

Review Process

Upon receipt of the AA&S request form, HHSC will assign a case number to the submitted request. All requests will be reviewed in accordance with the YES Waiver Policy Manual. If additional information is needed to complete the review process, WPO staff will have three business days to provide any additional information or documentation that has been requested. Once HHSC has finished reviewing the request, the WPO will be notified of the decision by email.


Detailed Instructions

The Wraparound Provider Organization completes this section.

Date — Enter the date the service was discussed with the Child and Family Team

CMBHS ID No. — Enter the participant’s Clinical Management for Behavioral Health Services (CMBHS) ID number.

Wraparound Provider Organization — Enter the Wraparound Provider Organization’s name.

Name of Wraparound Facilitator — Enter the Wraparound facilitator’s name.

Name of the Wraparound Supervisor — Enter the name of the Wraparound supervisor who has reviewed the AA&S request form. HHSC will contact the Wraparound supervisor with questions about the AA&S.

Comprehensive Waiver Provider — Enter the Comprehensive Waiver Provider organization’s name.

Participant Name — Enter the participant’s name.


Part I: Requested Service

The Wraparound Facilitator completes this section that address the related condition and the expected benefits of the requested item/service.

Description and Cost of Adaptive Aid and Support (AA&S) Request — Enter the individual item/service requested, including details, specification, or brand names as necessary to describe the request. Include the total cost of the request and where the request will be purchased.

Description of Medical Necessity for AA&S as it pertains to the reason for referral and prevention of out-of-home placement — Provide a detailed description of the participant’s functional limitation(s) relevant to the requested item. Describe why the item is necessary and how the item benefits the participant in terms of treatment, rehabilitation, or ability to compensate for functional limitations.

A description of how the AA&S will affect a service under the approved service plan to decrease or eliminate barriers to services and increase the participant’s access to their community — Provide a detailed description of how the requested item will supplement authorized services offered included in the YES Waiver service array. Include a description of how the AA&S is intended to be used by the participant to address the reason for referral and how the Child and Family Team is incorporating the AA&S as a part of plan of care.


Part II: Only required for requests that are over $500

The Wraparound facilitator, with the assistance of the Comprehensive Waiver Provider Organization representative if necessary, completes this section related to cost of item or service requested.

Has the YES Comprehensive Waiver Provider obtained three bids? — Select Yes or No. If the answer is yes, outline bids, including the name of service or item and cost of each item.

Is this request or bid the most cost-effective option? — Select Yes or No. If the answer is no, provide the reason for not choosing the most cost-effective option.


Part III: To be completed by the Wraparound Supervisor

The Wraparound supervisor must review the request with the Wraparound facilitator to confirm that the request meets YES Waiver policy criteria and that the Wraparound process has been followed according to the Wraparound model.

Per YES Waiver policy, this request meets criteria for what is an allowable AA&S. — The Wraparound supervisor must review the YES Waiver Policy Manual outlining policy requirements for AA&S, including the Non-Billable and Heightened Scrutiny requirements. Select Yes or No.

AA&S requested is tied to the participant’s SED and reason for referral and is medically necessary and mandatory to prevent institutionalization and out-of-home placement.— Select Yes or No.

AA&S requested is tied to a strategy associated with an underlying need that was identified during Child and Family Team meetings in fidelity to the Wraparound model — Select Yes or No.

All other strategies, payment, discounts, community resources have been explored and exhausted through the team task assignments and Medicaid is the payer of last resort. — Select Yes or No.

If the request is made before the first CFT meeting, the requested AA&S is tied to a crisis or safety plan and is necessary prior to the first CFT meeting. — Select Yes or No. If answer is yes, explain — Describe how the AA&S is included in the crisis/safety plan.

YES Program Supervisor Signature — The YES Program signature signs and dates the form.

Comprehensive Waiver Provider (CWP) Signature — The Comprehensive Waiver Provider representative signs and dates the form.


Part IV: HHSC Authorization Status

To be completed by HHSC only.

HHSC YES Waiver Staff Determination and Signature — HHSC indicates a decision of the AA&S Form.

Approved — Based on information presented, HHSC agrees that the item requested is justified based on necessity and appropriateness of the item/service. The WPO must attach the AA&S form, signed by HHSC, into the CMBHS system in the IPC Document. A brief description of the AAS must be included in the IPC AA&S justification box. Note: The Adaptive Aid and Support Request is not formally authorized until it is approved in CMBHS. Receipts of purchased items must be retained in the participant’s file.

Denied—Based on information presented, the item or service does not meet HHSC requirements and is not authorized.

  • Do not submit the AA&S request into the CMBHS system.
  • The WPO must send Forms 2800 and 2801, Denial of Eligibility and Fair Hearing Request forms to the participant. The WPO must include the reason for denial provided by HHSC.