Form 8590, Request for Approval to Withdraw an Enrollment Offer

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Documents

Effective Date: 2/2022

Purpose

Form 8590 is used by the local intellectual and developmental disability authority (LIDDA) to obtain approval from the Texas Health and Human Services Commission (HHSC) to withdraw an enrollment offer for the Home and Community-based Services (HCS) Program or the Texas Home Living (TxHmL) Program.

When to Prepare

Before withdrawing an HCS or TxHmL program enrollment offer, the LIDDA must obtain HHSC approval. The LIDDA must request approval to withdraw the enrollment offer if the:

  • LIDDA was unable to contact the person or legally authorized representative (LAR) and the person or LAR has not responded to the enrollment offer within 30 calendar days after receiving the offer. Note: If you are unable to locate the individual/LAR after the first 30 days, reach out to the designated slot monitor for additional contact information; 
  • LIDDA was able to contact the person or LAR and made the enrollment offer, but the person or LAR has not responded to the offer within 30 calendar days after the deadline date identified on Form 8592, Deadline Notification;
  • Person or LAR has not documented the choice of HCS or TxHmL services or returned Form 8601,  Verification of Freedom of Choice, within seven calendar days after receiving the form;
  • Person or LAR has accepted the enrollment offer, but has not documented their choice of a provider and returned the form to the LIDDA within 30 calendar days after receiving a provider list; 
  • Person or LAR accepted the enrollment offer, but has not completed activities necessary for completing enrollment; or
  • LIDDA has been informed that the person is no longer residing in Texas and currently does not plan to return to Texas. 

Do not submit this form if the person is deceased. Instead, notify the slot monitor by email and submit Form 8601. Enter “deceased” and the date of death (if known) on the form. Only the LIDDA representative’s signature is required. Do not mail Form 1068, Withdrawal of Offer for Home and Community-based Services (HCS) Program, or Form 1069, Withdrawal of Offer of Texas Home Living Program.

A completed Form 8590 must be submitted in separate attachments for each person, and the LIDDA must name each completed Form 8590 with the following file naming convention: 

  • Individual’s last name
  • Individual’s first name
  • Slot type number
  • WD
  • Date of the withdrawal letter

Example: SmithBob114WD10-05-2021

Note: Multiple withdrawal requests sent in one PDF will be returned without being processed.

Submittal

The LIDDA must email completed Form 8590 to the designated slot monitor using a secure email method. The LIDDA must include the slot type number for the enrollment offer and the type of request in the subject line. Example: “Slot Type 114 - Request for Approval to Withdraw an Enrollment Offer.” 

If the LIDDA does not have access to a secure email method, the LIDDA must email the designated slot monitor to request a secure email. The LIDDA can then reply to a secure email from HHSC to submit the form.

Detailed Instructions

Section 1, LIDDA’s Information

Today’s Date — Enter the date the LIDDA is submitting the form to HHSC.

LIDDA Name — Enter the name of the LIDDA.

LIDDA Component Code — Enter the component code of the LIDDA.

LIDDA Contact Person — Enter the name of the contact person for the LIDDA.

Area Code and Phone No. — Enter the area code and phone number of the LIDDA contact person.

Email — Enter the email address of the LIDDA contact person.

Section 2, Person’s Information

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

HCS or TxHmL — Check the appropriate box to indicate the program being offered.

Slot Type No. — Enter the slot type number as stated on the release notice from HHSC.

Client Assignment and Registration (CARE) Identification No. — Enter the person’s CARE ID number.

Medicaid No. (if known) — Enter the person’s Medicaid number as shown in the CARE C63, Medicaid Eligibility Search, screen. If no Medicaid number is shown in the CARE C63 screen, leave this field blank.

Date LIDDA Received Release Notice from HHSC — Enter the date the LIDDA received the release notice from HHSC. Refer to the release notice from HHSC.

Date LIDDA Mailed the Enrollment Offer — Enter the date the LIDDA mailed Form 1067, Offer of Home and Community-based Services (HCS) Program, or Form 1070, Offer of Texas Home Living (TxHmL) Program, and Form 8592, Deadline Notification, to the person or legally authorized representative (LAR).

Enrollment Due Date Per Release Notice from HHSC — Enter the enrollment due date as stated on the release notice from HHSC.

Extended Due Date (if approved by HHSC) — If HHSC has approved an enrollment due date extension, enter the latest approved extension date. If HHSC has not approved an enrollment due date extension, leave this field blank.

Section 3, Reason for Requesting Approval to Withdraw an Enrollment Offer – This section is required. Check only one. — Check the box that best describes the reason for requesting approval to withdraw the enrollment offer.

  1. LIDDA was unable to contact the person or legally authorized representative (LAR) and the person or LAR has not responded to Form 1067, Offer of Home and Community-based Services (HCS), or Form 1070, Offer of Texas Home Living Program, within 30 calendar days after the deadline date identified on Form 8592, Deadline Notification. Note: For this reason, before submitting this form, the LIDDA must contact the slot monitor to ask if HHSC has any different contact information available for the person.
  2. LIDDA was able to contact the person or LAR and made the enrollment offer, but the person or LAR has not responded to the offer within 30 calendar days after the deadline date identified on Form 8592.
  3. LIDDA made the enrollment offer, but the person or LAR has not documented their choice on Form 8601, Verification of Freedom of Choice, and returned the form to the LIDDA within seven calendar days after receiving the form.
  4. Person or LAR accepted the enrollment offer but has not documented their choice of provider on Form 1049, Initial Documentation of Provider Choice, or on Form 1052, Public Provider Choice Request, and returned the form to the LIDDA within 30 calendar days after receiving a provider list.
  5. Person or LAR accepted the enrollment offer but has not participated in activities necessary for completing enrollment. Examples: The person or LAR has missed scheduled meetings and did not return calls to reschedule. The person or LAR has chosen not to apply for Supplemental Security Income (SSI) or Medicaid benefits.
  6. LIDDA has been informed that person is no longer residing in Texas and currently does not plan to return to Texas. Person’s current state or country is . . . Note: For this reason, the LIDDA may skip Section 4.

Section 4, Documentation of Attempts - This section is required unless otherwise indicated in Section 3.  Document each phone and/or in-person attempt made by the LIDDA in chronological order (i.e., earliest to latest). At least three attempts are required and if no attempts were “in-person,” the LIDDA must document the reason(s) for not making an “in-person” visit.

Date — Enter the date of each attempted contact in chronological order (i.e., earliest to latest).
Type — For each attempt, select the type of attempt that was made on the specified date (i.e., by phone or in-person).

Area Code and Phone No. or Address — For each attempt made “by phone,” enter the area code and phone number the LIDDA called to try to contact the person or LAR. For each attempt made “in-person,” enter the address the LIDDA visited to try to locate the person or LAR.

Notes — Document the details of each attempt. For each attempt made “by phone,” include whether the call was answered, who you spoke with or if a message was left. For each attempt made “in-person,” include whether anyone was home, whether the door was answered and if you were able to speak to anyone involved with the individual. 

Reason(s) for Not Making an “In-Person” Attempt – Document the reason.

Section 5, HHSC Use Only — These fields are completed by HHSC staff only.

Date Received, Slot Monitor Name and Email – HHSC staff enter the information.

Approved – The LIDDA mails Form 1068 or Form 1069 (recommended); or its own HCS or TxHmL withdrawal letter, which must contain the same information as Form 1068 or 1069, via USPS certified mail and emails a copy to the slot monitor. HHSC updates the offer status after the slot monitor receives a copy of the certified mail receipt and appropriate withdrawal form or letter. 

Not Approved – The LIDDA must follow the instructions provided by the slot monitor.