Source: https://hhs.texas.gov/laws-regulations/handbooks/skh/section-4000-star-kids-community-services
Timestamp: 2019-04-20 20:24:45+00:00

Document:
This section outlines the delivery of STAR Kids community long term services and supports. Sections 4100-4520 describe Medicaid state plan long term services and supports, assessment and reassessment requirements, and provider requirements.
Sections 4600-4922 describe services available to members receiving Medically Dependent Children Program (MDCP) services, service requirements and limitations, and provider requirements.
a setting on the grounds of, or with the characteristics of, an institution.
Provider owned and controlled settings are also excluded from CFC because those providers are paid for CFC-like services as part of the provider’s rates, and to provide CFC would be duplicative.
In addition, assessment for CFC services and the development of a member's service plan must be person-centered, per 42 CFR §441.665. STAR Kids managed care organizations may not require CFC providers to obtain a denial or explanation of benefits from a member's primary insurance before seeking reimbursement for CFC services.
have an assessed functional need for CFC services.
All STAR Kids members are Medicaid eligible. Members whose eligibility is established due to eligibility for the Youth Empowerment Services (YES) or Medically Dependent Children Program (MDCP) waivers are eligible for CFC services, per § 1902(a)(10)(A)(ii)(VI) of the Social Security Act, as long as they receive at least one waiver service per month, as these members meet eligibility for an institution providing psychiatric services and an NF, respectively.
A member may not be authorized to receive both Personal Care Services (PCS) and CFC services at the same time.
For members with physical disabilities, the SK-SAI contains the elements necessary for Texas Medicaid & Healthcare Partnership (TMHP), on behalf of the Texas Health and Human Services Commission (HHSC), to determine if a member meets medical necessity for the level of care provided in a hospital or nursing facility. Once the SK-SAI is completed, if the STAR Kids managed care organization (MCO) seeks a determination of medical necessity for Community First Choice (CFC) services, the MCO must indicate so before submitting the assessment. The MCO must obtain the member's physician's signature on Form 2601, Physician Certification, certifying the member requires nursing facility services or alternative community based services under the supervision of a physician.
Further information about the medical necessity determination process for CFC may be found in Section 3110, Assessment of Medical Necessity for Community First Choice.
Upon notification from the MCO, Local Intellectual or Development Disability Authorities (LIDDAs) conduct assessments to determine whether a member meets the level of care (LOC) provided by an intermediate care facility for individuals with intellectual disabilities or related conditions (ICF/IID). In addition to the ID/RC, the LIDDA must collect information necessary to complete a Determination of Intellectual Disability (DID), if a member does not have one on file. The LIDDA submits this information to the state for a determination of ID/RC. The state notifies both the LIDDA and the member's MCO about the determination. If a member meets the LOC provided in an ICF/IID, the MCO completes the CFC functional assessment. If the member does not agree to the CFC service plan or refuses CFC services, the MCO must notify the LIDDA within 10 business days of the member ending CFC services.
A comprehensive provider of mental health rehabilitative services or a Local Mental Health Authority (LMHA) conduct the CANS or ANSA and a licensed practitioner determines whether the member meets an inpatient psychiatric facility level of care. If the member meets that LOC, or receives services through the Youth Empowerment Services program, the MCO conducts the CFC functional assessment if the member requests CFC services.
Community First Choice services are personal assistance services, habilitation, emergency response services and support management.
Assistance with health-related tasks. Health-related tasks, in accordance with state law, include tasks delegated by a registered nurse, health maintenance activities and extension of therapy. An extension of therapy is an activity that a speech therapist, physical therapist or occupational therapist instructs the member to do as follow-up to therapy sessions. If appropriate, the member's attendant can assist the member in accomplishing such activities with supervision, cueing and hands-on assistance.
In the Consumer Directed Services (CDS) model, the member or legally authorized representative determines health-related tasks without a nurse assessment, in accordance with state laws, §531.051(e), Texas Government Code, and 22 Texas Administrative Code, §225.4.
CFC PAS is the same service (i.e., attendant care) as Personal Care Services (PCS). The only difference is the member's level of care (LOC) and how the service is billed. Information used to build a plan of care for CFC PAS may be found in the STAR Kids Screening and Assessment Instrument (SK-SAI) Personal Care Assessment Module (PCAM). The PCAM is administered if triggered by the appropriate items on the SK-SAI (see Appendix I, MCO Business Rules for SK-SAI and SK-ISP) or if the member requests CFC services. Although the PCAM may be triggered if the member has an attendant care need, the member may only receive CFC PAS if he meets CFC level of care criteria.
Members may choose to receive CFC PAS only if they do not need or want CFC habilitation.
Information used to build a plan of care for CFC habilitation may be found in the STAR Kids Screening and Assessment Instrument (SK-SAI) Personal Care Assessment Module (PCAM) in Section P. This section of the PCAM should only be administered after the assessor or service coordinator explains the CFC benefit and the member wishes to be assessed for CFC emergency response services (ERS).
CFC ERS provides backup systems and supports to ensure continuity of services and supports. Reimbursement for backup systems and supports is limited to electronic devices to ensure continuity of services and supports and are available for members who live alone, who are alone for significant parts of the day, or have no regular caregiver for extended periods of time and who would otherwise require extensive routine supervision. A member must be cognitively able to recognize an emergency situation and be able to recognize the need to use ERS for ERS to be authorized.
Need for ERS is assessed using the SK-SAI, Section Z.
Community First Choice emergency response services (ERS) is designed to assist individuals who do not require supervision during the day or are alone for large parts of the day, and are cognitively able to recognize an emergency. This service connects a member to an ERS provider who notifies local authorities, like paramedics or a fire department, to a member's emergency. This service is not routinely authorized for members who are minors.
Community First Choice (CFC) support management provides voluntary training on how to select, manage and dismiss attendants. Support management is available to any member receiving CFC services, regardless of the selected service delivery model.
Need for support management is assessed using the STAR Kids Screening and Assessment Instrument, Section Z.
To ensure the TMHP evaluates the submitted SK-SAI for the nursing facility LOC, the MCO must submit the SK-SAI with field Z5a=1 to indicate that an MN determination is needed. TMHP's determination will be communicated to the MCO on the substantive response file, as specified in Appendix I.
If TMHP determines that the member does not meet MN, the member is not eligible to receive CFC through the nursing facility LOC. This does not preclude the member or MCO from seeking determination of a different institutional LOC. If TMHP determines that that the member meets MN and the functional assessment conducted by the MCO indicates a need for CFC services, the member is eligible to receive CFC through the nursing facility LOC.
For members requiring a reassessment of medical necessity (MN) for a nursing facility level of care for continued eligibility for Community First Choice services, the managed care organization (MCO) administers the entire STAR Kids Screening and Assessment Instrument (SK-SAI), including appropriate modules, no earlier than 90 days before or no later than 30 days prior to the expiration of the member’s current individual service plan (ISP) on file. The MCO must indicate yes in Field Z5a to notify Texas Medicaid & Healthcare Partnership (TMHP) that an MN determination is required. Form 2601, Physician Certification, is not required for reassessments of MN if the member's file contains the form for a previous assessment. The MCO must ensure that the reassessment is timed to prevent any lapse in service authorization.
Described in Section 4111, Determining Institutional Level of Care, if the managed care organization (MCO) knows or believes a member has an intellectual disability or related condition (ID/RC), the MCO refers the member to the Local Intellectual and Developmental Disability Authority (LIDDA). The LIDDA and the MCO communicate during the assessment process through a Secure File Transfer Protocol (SFTP) site, updating the file as the member moves through the assessment process. The MCO initiates a referral to the LIDDA by adding a referred member to the spreadsheet. The MCO must provide the member's named service coordinator and his contact information to assist in coordinating assessment activities. Following completion of the determination of intellectual disability and ID/RC, the LIDDA submits the assessment for a determination of level of care to the state. The Texas Health and Human Services Commission (HHSC) informs both the LIDDA and MCO of the determination. If a member is determined to not meet the level of care provided in an intermediate care facility (ICF), the MCO is responsible for notifying the member through the established denial process. HHSC attends the fair hearing if one is requested.
If a member meets an ICF level of care, the MCO follows the process outlined in Section 4140, Functional Assessment for Community First Choice Services, to determine the member's service plan. When the member selects a service provider, the MCO updates the SFTP site noting the member's selected provider. If a member declines or discontinues Community First Choice services, the MCO must update the SFTP site noting the date the member declined or discontinued services.
Ninety days prior to the expiration of the member's level of care assessment, the Local Intellectual and Development Disability Authority (LIDDA) updates the Secure File Transfer Protocol (SFTP) site requesting the managed care organization (MCO) confirm the member requires a reassessment of an intermediate care facility (ICF) level of care. If a member is receiving Community First Choice (CFC) services, the MCO indicates the member requires a reassessment. If the member declined or discontinued CFC services, the MCO indicates the member does not require a reassessment. The LIDDA and the MCO follow the processes outlined in Section 4132, Assessment for an Intermediate Care Facility Level of Care, for all reassessments.
If a member continues to meet an ICF level of care, the MCO follows the process outlined in Section 4140, Functional Assessment for Community First Choice Services, to determine the member's service plan. When the member selects a service provider, the MCO updates the SFTP site noting the member's selected provider. If a member declines or discontinues CFC services, the MCO must update the SFTP site noting the date the member declined or discontinued services.
Described in Section 4111, Determining Institutional Level of Care, if the managed care organization (MCO) knows or believes a member has serious emotional disturbance (SED) or serious and persistent mental illness (SPMI), the MCO refers the member to the Local Mental Health Authority (LMHA) or to a comprehensive provider of mental health rehabilitative services. This provider conducts the Child and Adolescent Needs or Strengths (CANS) or Adult Needs and Strengths Assessment (ANSA), depending on the member's age. Based on an algorithm, the assessment determines the member's level of care (LOC). A licensed practitioner must concur with the assessment or may deviate a member to a higher or lower LOC, based on his clinical judgement. A licensed practitioner must review the CANS or ANSA at least annually. Mental health rehabilitative services are reassessed more frequently than the LOC for Community First Choice (CFC) services. For the purposes of eligibility for CFC services, a member's CANS or ANSA is valid for 12 months.
Members enrolled in the Youth Empowerment Services (YES) waiver meet a psychiatric institutional level of care and do not require an additional assessment of LOC to receive CFC services. These members may be assessed by their health plan for functional necessity of CFC services at any time while enrolled in YES.
Assessment of a psychiatric institutional level of care (LOC) must be reassessed annually for continued eligibility for Community First Choice (CFC) services. Sixty days prior to the expiration of the member's CFC service plan, the managed care organization (MCO) must refer the member to the Local Mental Health Authority (LMHA) or to a comprehensive provider for mental health rehabilitative services. This provider conducts the Child and Adolescent Needs or Strengths (CANS) or Adult Needs and Strengths Assessment (ANSA), which must be reviewed by a licensed practitioner to determine if the member continues to meet a psychiatric institutional LOC. If the member continues to meet this LOC, the MCO conducts the CFC functional assessment.
If the member does not meet a psychiatric institutional level of care, the MCO may conduct the STAR Kids Screening and Assessment Instrument (SK-SAI) to determine if the member meets medical necessity for a nursing facility LOC. If the MCO believes the member will not meet medical necessity and does not have an intellectual or developmental disability, the MCO must notify the member or his representative of the denial for CFC services. The member may be eligible for personal care services, if functionally necessary.
The member or his legally authorized representative requests an assessment for CFC or personal care services.
If triggered, the service coordinator completes the PCAM (sections J, K, L, M, N, O, and P) to determine attendant care needs. Section P should only be completed if the member is specifically seeking CFC services. The service coordinator also completes SK-SAI Section Y, Worksheets, to assist in developing a recommended number of hours. Based on the assessment, the service coordinator develops a recommended service plan for the delivery of CFC services. The service coordinator works with the member or his representative to locate an appropriate provider and sends an authorization to the selected provider.
The need for and the amount and duration of Community First Choice services must be reassessed every 12 months, or when requested due to a change in the member's health condition or living situation.
Personal care services (PCS) is a benefit under the Early and Periodic Screening, Diagnosis, and Treatment Comprehensive Care Program, known in Texas as the Texas Health Steps Comprehensive Care Program (THSteps-CCP). PCS is available to STAR Kids members from birth through age 20. PCS is considered medically necessary when a member requires assistance with activities of daily living (ADLs), instrumental activities of daily living (IADLs), or health maintenance activities (HMAs) because of physical, cognitive, or behavioral limitations related to the member's disability or chronic health condition. The member's disability or chronic health condition must be substantiated by a physician statement of need. STAR Kids managed care organizations (MCO) may not require PCS providers to obtain a denial or explanation of benefits from a member's primary insurance before seeking reimbursement for PCS.
As defined by law, the scope of ADLs, IADLs, and HMAs includes a range of activities that healthy, nondisabled adults can perform for themselves. Developing children gradually and sequentially acquire the ability to perform ADLs and IADLs for themselves. PCS does not include ADL, IADL or HMA activities that a typically developing child of the same chronological age would not be able to safely and independently perform without adult supervision. As required by law, a member's responsible adult must perform ADLs, IADLs and HMAs on behalf of the individual to the extent that the need to do so would exist in a typically developing child of the same chronological age. Medicaid PCS benefits are limited to situations where the need for assistance to perform the ADLs, IADLs and HMAs is caused by the member's physical, cognitive, or behavioral limitation related to the member’s disability or chronic health condition. PCS includes direct intervention to assist the individual in performing a task or indirect intervention by cueing the individual to perform a task.
Individuals must have a medical or cognitive need for specific tasks. PCS is medically necessary only when an individual has a physical, cognitive, or behavioral limitation related to the individual’s disability or chronic health condition that inhibits the individual’s ability to accomplish ADLs, IADLs or HMAs.
Hands-on assistance, cueing, redirecting, or intervening to accomplish the approved PCS task.
Whether services are needed based on the physician’s statement of need and the assessment for personal care described in Section 4210 that follows.
community setting in which the member is located.
The MCO must not reimburse PCS that duplicates services that are the legal responsibility of the school district. The school district, through the School Health and Related Services (SHARS) program, is required to meet the member's personal care needs while the member is at school. However, if those needs cannot be met by SHARS or the school district, documentation may be submitted to the MCO with documentation of medical necessity.
PCS may not be authorized in a hospital, nursing facility, institution providing psychiatric care, or an intermediate care facility for individuals with intellectual or developmental disabilities.
PCS may not be used as respite, child care, or for the purposes of restraining a member. PCS may be authorized in a group setting.
A member may not be authorized to receive both PCS and Community First Choice (CFC) services at the same time.
Texas Home Living (TxHmL) Program.
The member or his legally authorized representative requests an assessment for Community First Choice (CFC) or PCS.
If triggered, the service coordinator completes the PCAM (sections J, K, L, M, N, and O) to determine attendant care needs. Section P should not be completed if the member is only seeking PCS and not CFC. The service coordinator also completes SK-SAI Section Y, Worksheets, to assist in developing a recommended number of hours. Based on the assessment, the service coordinator develops a recommended service plan for the delivery of PCS. The service coordinator works with the member or his representative to locate an appropriate provider and sends an authorization to the selected provider.
The need for and the amount and duration of personal care services (PCS) must be reassessed every 12 months, or when requested due to a change in the member's health or living condition. The managed care organization must obtain a new physician statement of need to substantiate the member's continued need for PCS upon each annual reassessment.
is employed by the member or his legally authorized representative (LAR) through the Consumer Directed Services (CDS) option.
has demonstrated the competence necessary, when competence cannot be demonstrated through education and experience, to perform the personal assistance tasks assigned by the HCSSA or by the member or the member's responsible adult or LAR acting as employer through the CDS option.
is not the spouse of the member.
Private duty nursing (PDN) is a benefit under the Early and Periodic Screening, Diagnosis, and Treatment Comprehensive Care Program, known in Texas as the Texas Health Steps Comprehensive Care Program (THSteps-CCP). PDN is available to STAR Kids members from birth through age 20. PDN services must be available when the services are medically necessary to correct or ameliorate a member's disability, physical or mental illness, or condition. The services correct or ameliorate when the services improve, maintain or slow the deterioration of the member's health status.
The services correct or ameliorate the member's disability, physical or mental illness, or condition. Nursing services correct or ameliorate the member's disability, physical or mental illness, or condition when the services improve, maintain or slow the deterioration of the member's heath status.
There is no third party resource financially responsible for the services.
PDN should prevent prolonged and frequent hospitalizations or institutionalization and provide cost effective and quality care in the most appropriate, least restrictive environment. PDN provides direct nursing care and caregiver training and education. The training and education is intended to optimize member health status and outcomes, and to promote family-centered, community-based care as a component of an array of service options.
PDN is considered only when the services are consistent with the definition of "nursing" as described in the Texas Nursing Practice Act or its implementing regulations. PDN must not be considered for reimbursement if the services are intended solely to provide respite care or child care, or do not directly relate to the member's nursing needs.
deny or reduce the amount of authorized PDN services because the member's responsible adult(s) is trained and capable of performing such services, but chooses not to do so.
The member is being assessed for Community First Choice services or the Medically Dependent Children Program.
If triggered, the service coordinator completes the NCAM addendum (Section Q) to determine the member's nursing needs. The service coordinator also completes SK-SAI Section Y, Worksheets, to assist in developing a recommended number of hours. Based on the assessment, the service coordinator develops a recommended service plan for the delivery of PDN. The service coordinator works with the member or his representative to locate an appropriate provider and sends an authorization to the selected provider.
At a minimum, the need for and the amount and duration of private duty nursing must be reassessed 90 days following initial authorization and every six months, or when requested due to a change in the member's health or living condition. A physician order must be renewed with any reassessment.
Private duty nursing (PDN) may be provided by a licensed Home and Community Support Services Agency (HCSSA), an independently enrolled registered nurse (RN) or a licensed vocational nurse (LVN) under the supervision of an RN, contracted with the STAR Kids managed care organization.
PDN must not be provided by a member's legally responsible adult if the member is under age 18 or the spouse of the member.
Private duty nursing (PDN) services and nursing services provided through a Prescribed Pediatric Extended Care Center (PPECC), as described in Section 4400 that follows, are considered to be an equivalent level of nursing care. An individual who qualifies for PDN will qualify for PPECC.
An individual has a choice of PDN, PPECC, or a combination of both PDN and PPECC for ongoing skilled nursing. Members must be informed of their service options for ongoing skilled nursing (PDN or PPECC) when PPECC services are available in the service delivery area. A member may receive both PDN and PPECC on the same day, but not at the same time (e.g., PDN may be provided before or after PPECC services are provided). The combined total hours between PDN and PPECC services is not anticipated to increase unless there is a change in the individual's medical condition or the authorized hours are not commensurate with the individual's medical needs. Per §363.209 (c)(3), PPECC services are intended to be a one-to-one replacement of PDN hours unless additional hours are medically necessary.
Because the total number of approved skilled nursing hours do not decrease, the Texas Health and Human Services Commission (HHSC) views a shift from PDN to PPECC as a provider change, and not an adverse action. The fee-for-service Nursing Addendum to the Plan of Care for PPECCs and PDN includes updated individual acknowledgements, including an acknowledgement that PDN hours may decrease if shifting the hours to the PPECC, or vice versa.
Achieving a one-to-one replacement of existing PDN hours with PPECC (or vice versa) to prevent service duplication will require an examination of authorizations for both PDN and PPECC services, including a review of the 24-hour flow sheet for nursing care. For example, when an individual with PDN decides to shift hours to a PPECC, then the PDN authorized hours will be decreased by the amount of hours shifted to a PPECC, unless there is a change in the individual’s medical condition requiring additional hours, or the authorized hours are not commensurate with the individual's medical needs. The PDN provider would be notified by the managed care organization of the revised (decreased) authorized hours. The PDN provider may submit a revision request with documentation to justify medical necessity for any additional hours requested. The PPECC and PDN providers are expected to coordinate on the respective plan of care for the individual. The service coordinator is expected to play a role in ensuring the coordination between PPECC and PDN service providers and authorized services.
Resides with the responsible adult and does not reside in any 24-hour inpatient facility, including a general acute hospital, skilled nursing facility, intermediate care facility or special care facility.
PPECC services require prior authorization and are intended as an alternative to private duty nursing (PDN). However, an admission authorized under this section is not intended to supplant the right of a member to access PDN, Personal Care Services (PCS), Home Health Skilled Nursing (HHSN), Home Health Aide (HHA), and therapies (physical therapy, occupational therapy, speech therapy), as well as respiratory therapy and Early Childhood Intervention services rendered in the member's residence when medically necessary.
Note: PPECC services may be billed on the same day as PDN, PCS, HHSN and HHA, but PPECC services must not be billed for the same span of time a member receives these other services.
is revised for each authorization of services, or more frequently as the ordering physician deems necessary.
Transportation services to and from a PPECC. Transportation must be provided by a PPECC when a member has a stated need or a prescription for transportation to the PPECC. When a PPECC provides transportation to a member, a nurse employed by the PPECC must be on board the transport vehicle. The member must be able to utilize transportation services offered by the PPECC with the assistance of a PPECC nurse to and from the PPECC, rather than a non-emergency ambulance. Transportation is billed separately by the PPECC when utilized by a member. A non-emergency ambulance may not be utilized for transport to and from a PPECC.
Note: A member or the member's responsible adult may decline a PPECC's transportation and choose to be transported by other means, including his or her responsible adult. A member’s legally authorized representative is not required to accompany a member when the member receives services in a PPECC, including transportation services to and from the center and therapy services that are billed separately. Fee-for-service Medicaid does not require prior authorization for the transportation billing code. Rather, authorization for PPECC services implies authorization for transportation.
services covered separately by Texas Medicaid, such as therapies or durable medical equipment, or individualized comprehensive case management beyond that required for service coordination.
If triggered, the service coordinator completes the NCAM addendum (Section Q) to determine the member's nursing needs. The service coordinator also completes SK-SAI Section Y, Worksheets, to assist in developing a recommended number of hours. Based on the assessment, the service coordinator develops a recommended service plan for the services of a PPECC. The service coordinator works with the member or his representative to locate an appropriate provider and sends an authorization to the selected provider.
Note: If an individual qualifies for PDN, the individual will qualify for PPECC.
At a minimum, the need for and the amount and duration of services from a Prescribed Pediatric Extended Care Center must be reassessed 90 days following initial authorization and every 180 days following, or when requested due to a change in the member's health or living condition. A physician order must be renewed with any reassessment.
A Prescribed Pediatric Extended Care Center (PPECC) must be currently licensed (temporary, initial or renewal license), comply with 40 Texas Administrative Code Chapter 15 (relating to Licensing Standards for Prescribed Pediatric Extended Care Centers), and be contracted with a member’s STAR Kids managed care organization (MCO) to provide services to that member. Contractual provisions for continuity of care apply. PPECCs do not provide emergency services. PPECCs must follow the safety provisions in state PPECC licensure requirements, including the adoption and enforcement of policies and procedures for a member’s medical emergency. PPECCs must call for emergency transport to the nearest hospital when emergency services are needed by a member in a PPECC. Per PPECC licensure requirements, services are non-residential, must be included in a PPECC plan of care (POC), and are limited to no more than 12 hours in a 24-hour period. Services may not be rendered overnight (9 p.m. to 5 a.m.).
Services outlined in the Texas Administrative Code, Title 1, Part 15, Chapter 636 (Texas Health Steps Comprehensive Care Program), Subchapter B (Prescribed Pediatric Extended Care Center Services), Rule §363.211 (Benefits and Limitations).
Early intervention services provided through the ECI program, which are subject to ECI policies.
(4) signed consent of the participant or participant's responsible adult documenting the choice of PPECC services. The signed consent must include an acknowledgement by the participant or the participant's responsible adult that he or she has been informed that other services such as private duty nursing might be reduced as a result of accepting PPECC services. Consent to share the participant's personal health information with the participant's other providers, as needed to ensure coordination of care, must also be obtained.
CCP Prior Authorization Request (requires ordering physician signature).
PPECC POC (requires ordering physician, PPECC RN and member/responsible adult signature). Note: Providers may use their own POC form, but it must contain the required elements per the Texas Medicaid Provider Procedures Manual.
Nursing Addendum to Plan of Care for Private Duty Nursing and/or PPECC (requires ordering physician, PPECC RN, and member/responsible adult signature). This form contains required individual and physician acknowledgements and consent.
When an MCO decides to use its own forms for PPECC authorizations, the forms must be equivalent to the fee-for-service forms, and are subject to approval by HHSC.
See Section 4330, Private Duty Nursing and Prescribed Pediatric Extended Care Center Services, for details on coordination of services between PDN and PPECC. Both PDN and PPECC are ongoing skilled nursing services, and are considered equivalent levels of nursing care. A member has a choice to receive PDN, PPECC, or a combination of both services.
Day Activity and Health Services (DAHS), also called adult day care, is a Medicaid state plan service available to STAR Kids members ages 18 and older who require the service because of a chronic medical condition and are able to benefit therapeutically from the service. DAHS provides attendant care in a facility setting under the supervision of a nurse. Services include nursing, physical rehabilitation, nutrition, social activities and transportation when another means of transportation is unavailable. STAR Kids managed care organizations may not require DAHS providers to obtain a denial or explanation of benefits from a member's primary insurance before seeking reimbursement for DAHS.
The potential for therapeutic benefit must be established by a physician's assessment and requires a physician's order.
the DAHS nurse determines a member needs to be reassessed.
The member or his legally authorized representative must sign the health assessment each time the nurse completes or revises the form. The health assessment must identify specific conditions that may affect a member's functioning.
Reassessment by a physician is required at least every 12 months for continued authorization. For this service, a physician assessment may be no older than 90 days from the date at which an authorization is requested.
a member's condition changes. If the change in condition necessitates, the facility nurse coordinates with the member's service coordinator or physician for a physician assessment.
To provide Day Activity and Health Services (DAHS), a facility must hold a current license from the Texas Health and Human Services Commission and comply with Texas Administrative Code, Title 40, Part 1, Chapter 98, Adult Day Care and Day Activity and Health Services Requirements.
Nursing services, which include a member’s nursing assessment, assistance with prescribed medications, counseling concerning health needs, and supervision of personal care services.
Physical rehabilitative services, which include restorative nursing and group/individual exercises with range of motion exercises.
dietary counseling and nutrition education for the individual and his family.
have sufficient staff to ensure the safety of members being transported to and from their homes.
Activities offered at the facility must be meaningful, fun, therapeutic and educational.
The Medically Dependent Children Program (MDCP) provides respite, flexible family support services, minor home modifications, adaptive aids, transition assistance services, supported employment, and employment assistance to prevent placement of individuals in long-term care facilities who are medically dependent and under 21 years of age and support deinstitutionalization of nursing facility residents under 21 years of age.
Only members who are assessed as meeting medical necessity (MN) and who have a slot in the MDCP waiver are eligible for MDCP services. Federal guidelines require that members must need and use one or more waiver services to qualify and maintain eligibility for MDCP. The minimum utilization of MDCP service required to maintain MDCP eligibility is dependent upon the member’s Medicaid eligibility and whether they utilize Community First Choice (CFC), as described in Section 1530, Unmet Need for at Least One Waiver Service.
CFC has been authorized, at a minimum, one MDCP service must be utilized at least once a month to qualify and maintain enrollment in MDCP.
CFC has not been authorized, at a minimum, one MDCP service must be utilized at least once during the member’s ISP year to qualify and maintain enrollment in MDCP.
If the member’s eligibility is not MAO and CFC has been authorized, at a minimum, one MDCP service must be utilized at least once during the member’s ISP year to qualify and maintain enrollment in MDCP.
If a member is offered enrollment in MDCP or at an MDCP member's reassessment, during the STAR Kids assessment, using the STAR Kids Screening and Assessment Instrument (SK-SAI), the service coordinator may discuss the member's needs as they relate to the available MDCP services. The service coordinator may develop a recommended individual service plan (ISP) if the member's Resource Utilization Group (RUG) is not known, as the RUG determines the member's budget.
Example: The service coordinator could ask the member and/or his caregiver if they would like respite or have a desire for employment services. The service coordinator could ask if the member requires adaptive aids, minor home modifications, or could benefit from flexible family support services. The service coordinator could inquire which services the member/caregiver would like more of, should the member's budget be unknown during the assessment. Based on the discussion, the service coordinator could develop a recommended ISP for that member and work with the member/caregiver in person or telephonically to develop a final service plan once the member's budget is known.
Respite is a service that provides temporary relief from caregiving to the applicant/member or his primary caregiver during the times when the primary caregiver would normally provide care. The primary caregiver may be the applicant's/member's parent(s), guardian, a family member or spouse, if married. STAR Kids managed care organizations (MCOs) may not require respite providers to obtain a denial or explanation of benefits from a member's primary insurance before seeking reimbursement for respite services.
In-home respite may be delivered by a Home and Community Support Services Agency (HCSSA), also called a home health agency, or through the Consumer Directed Services (CDS) option. Respite may be delivered by attendants or nurses employed through the CDS option. In-home respite is not limited to the individual’s place of residence. Respite may also be provided in other community settings when the situation does not exceed the limitations documented in Section 4720, Respite Limits. Other community settings could include the park, the respite provider’s home, or a home of the member's relative. Out-of-Home Respite may be provided in a facility setting, such as a nursing facility or hospital, or in a camp setting.
Respite is intended to provide relief to the primary caregiver. It may only be provided when a member's primary caregiver would normally provide the member's care. Respite may not be delivered while the member is in school or in a school setting. Respite must not be provided at the same time as a duplicative service, such as Community First Choice (CFC) or Private Duty Nursing (PDN). Duplication occurs when Medically Dependent Children Program (MDCP) respite provided by a nurse is rendered at the same time as another in-home nursing service (such as PDN), or when MDCP respite provided by an attendant is rendered at the same time as another attendant care service (such as CFC). Because respite is a service to provide relief to the primary caregiver, if the caregiver would normally be providing services, respite may be authorized at the same time. For example, a nurse providing PDN is in the member's home for the purpose of suctioning, monitoring vitals, etc., and an MDCP respite attendant is in the home at the same time providing CFC to the member to relieve the caregiver of tasks he would normally be responsible for performing. Circumstances which require two personnel for a two-person transfer are not considered a duplication of services. In that scenario, the private duty nurse and MDCP respite attendant could collaborate to accomplish the transfer.
STAR Kids MCOs may determine the number of units of respite to authorize for an MDCP member, based on the member and/or legally authorized representative's preferences and the member's approved cost limit. MCOs must develop internal processes related to respite service schedules, schedule changes, and policies regarding setting aside funds within the individual service plan (ISP). MCOs must develop a process to allow for flexible schedules and allow an MDCP member to "bank" respite hours to use at later point in the ISP year. MCOs must allow members to have flexibility in the use of respite hours, allowing members to carry over respite hours from week to week and month to month. A member cannot carry respite hours over from an expiring ISP to the new ISP. The MCO must document banked hours using Form 2605, Respite Tracking Tool.
In-home respite is not limited to the individual’s place of residence. Respite may also be provided in other community settings, which could include the park, the respite provider’s home or a home of the individual’s relative. In-home respite may be provided by a licensed Home and Community Support Services Agency (HCSSA), also called a home health agency, or the provider employed by a member or his legally authorized representative under the Consumer Directed Services (CDS) option.
A member's in-home respite is limited by the amount of the member's cost limit. If the member chooses the CDS option, the member is limited by his available budget. Managed care organizations may have additional policies and procedures regarding reserving capacity in a member's budget. The provision of in-home respite is documented on the individual service plan.
A delegated task is defined as a task that a practitioner or registered nurse (RN) delegates in accordance with state law. In general, the Texas Board of Nursing (BON) defines nurse delegation as authorizing an unlicensed person to provide nursing services while retaining accountability for how the unlicensed person performs the task. In brief, the Texas Occupations Code indicates a physician may delegate to a qualified and properly trained person acting under the physician's supervision any medical act that a reasonable and prudent physician would find within the scope of sound medical judgment to delegate. Only an RN may delegate to an attendant under his supervision, per BON rules. A member with a skilled task need may to use an attendant with delegated tasks if a practitioner or RN delegates the skilled task required to meet the member's needs.
If the member does not have a skilled task need for the delivery of respite, he does not have a need for an attendant with delegated tasks. If the member or primary caregiver requests the use of an attendant with delegated tasks, but the service coordinator or the Home and Community Support Services Agency provider determines the use of this provider type places the individual's health and welfare at risk, the service coordinator should not authorize an attendant with delegated tasks to deliver respite, unless determined appropriate by the member's physician.
If a member or legally authorized representative (LAR) employs an attendant under the Consumer Directed Services (CDS) option, delegation of certain tasks is not required under the CDS option. Form 1585, Acknowledgment of Responsibility for Exemption from Nursing Licensure for Certain Services Delivered through Consumer Directed Services, outlines what services cannot be delegated, such as specific tasks involved in the implementation of the care plan that require professional nursing judgment or intervention. If the member or his LAR is directing the member's services, he must sign Form 1585, acknowledging responsibility for the training and oversight of an attendant.
foster families approved by a DFPS child placing agency.
Facility-based respite is limited to 29 days per the individual service plan period. The 29-day limit applies to the total number of days a member receives respite in a hospital or nursing facility.
Respite may only be provided during the time the primary caregiver would usually provide care to the member. Respite may not be provided during the time the primary caregiver is at work, attending school or in job training. All respite settings must be located within the state of Texas.
Title 42 of the Code of Federal Regulations §441.301(b)(1)(ii) requires that home and community based services, like Medically Dependent Children Program (MDCP) services, not be provided in an institution. However, respite may be provided in a hospital or nursing facility (NF) only if the sole reason for the member's admission is respite. For example, if a member is admitted to a hospital for reasons such as illness, surgery or stabilization/treatments, respite must not be authorized concurrently.
The member may request to exceed the 29-day facility-based respite limit. Within five days of the request to exceed the 29-day limit, the managed care organization (MCO) must review the individual’s needs and the primary caregiver’s ability to meet those needs, and determine if the request falls within the respite criteria. The MCO must ensure there is no danger to the member’s health and welfare.
member's parent, representative, guardian or managing conservator, if the individual is under age 18.
FFSS include personal care supports for basic activities of daily living and instrumental activities of daily living, skilled task and delegated skilled task supports. FFSS promote community inclusion in typical child and youth activities through the enhancement of natural supports and systems and through recognition that these supports may vary by child, provider, setting and daily routine. Flexible family support services may be delivered by the Home and Community Support Services Agency and also may be delivered by attendants or nurses employed through the Consumer Directed Services option. FFSS are documented on the individual service plan. STAR Kids managed care organizations may not require FFSS providers to obtain a denial or explanation of benefits from a member's primary insurance before seeking reimbursement for FFSS.
The member's parent or guardian is responsible for basic child care either in or out of the member's home. Flexible family support services (FFSS) support the member's participation in child care when the service provided by the child care does not support the member's disability-related needs. If the member's child care is not able to meet the member's activities of daily living, instrumental activities of daily living, skilled task, non-skilled task or delegated skilled task needs, the service coordinator may authorize FFSS.
To determine the need for FFSS for participation in child care, the service coordinator must discuss the parent's or guardian's plan for obtaining basic child care and whether it will be provided in or out of the member's home or both. The delivery of FFSS does not include basic child care, which is watchful attention or supervision of the member while the primary caregiver is at work, in job training, or at school and not available. These remain responsibilities within the service delivered by the child care provider.
The caregiver's cost for child care does not impact the member's need for FFSS. The service coordinator must determine the amount of hours needed to support the member's needs within the Medically Dependent Children Program cost limit. The service coordinator should ask the caregiver about the member's personal and skilled task needs and the time needed to address those needs. The service coordinator should discuss the skill level required to assist the member to address necessary safeguards that ensure the member's health and welfare.
FFSS does not replace personal care services provided through Texas Health Steps or Community First Choice. FFSS are provided when a member regularly participates in child care in the home or out of the home, or participates in a community program or educational service. FFSS are authorized because of a change in the child's condition or when because of the child's condition, the child’s needs cannot be met. In these instances, additional care is required.
A member may indicate a desire for increased independence as he or she matures. If the member needs assistance with activities of daily living, instrumental activities of daily living, skilled task, non-skilled task or delegated skilled task, the service coordinator may authorize flexible family support services (FFSS) to help the member with his or her goal for independent living.
Independent living can be an arrangement that maximizes independence and self-determination and offers opportunities to be as self-sufficient as possible. Although independent living is not a Medically Dependent Children Program service, an independent living arrangement can provide life-skills training to assist members in acquiring the skills they will need to live independently as adults.
To determine the need for FFSS for independent living, the service coordinator must discuss the member's and primary caregiver's plan for the member's independent living. When identifying the member's need for this service, the service coordinator should address age appropriateness for the tasks required to meet these needs. The service coordinator must determine the amount of FFSS needed to support the member's needs. The service coordinator should discuss the skill level required to assist the member and the appropriateness of the living arrangement and service delivery regarding the member's age, health and welfare. FFSS may be used only when the primary caregiver is working, attending school or participating in job training.
A member can access flexible family support services (FFSS) to participate in post-secondary education. Post-secondary education institutions do not assist students with activities of daily living (ADL), instrumental activities of daily living (IADL), skilled task, non-skilled task or delegated skilled task needs. If a member has an ADL, IADL, skilled task, non-skilled task or delegated skilled task need prohibiting the member from participating in post-secondary education, the service coordinator may authorize FFSS so the member may participate in post-secondary education.
A member may enroll in a post-secondary school after first attending a secondary school, such as a high school. A post-secondary education may include vocational education and training, as well as participation in a college or university. These educational institutions are not subject to the Individuals with Disabilities Education Act. Post-secondary institutions can provide academic adjustments, but do not support the member's personal, skilled and delegated skilled task needs.
To determine the need for FFSS in post-secondary education, the service coordinator must identify the member's need for assistance and the amount of FFSS needed to support the member's needs. The service coordinator should identify the member's personal and skilled task needs and the amount of time needed to address those needs. The service coordinator should discuss the skill level required to assist the member and address necessary safeguards to ensure the member's health and welfare.
A delegated task is defined as a task that a practitioner or registered nurse (RN) delegates in accordance with state law. In general, the Texas Board of Nursing (BON) defines nurse delegation as authorizing an unlicensed person to provide nursing services while retaining accountability for how the unlicensed person performs the task. In brief, the Texas Occupations Code indicates a physician may delegate to a qualified and properly trained person acting under the physician's supervision any medical act that a reasonable and prudent physician would find within the scope of sound medical judgment to delegate. Only a Home and Community Support Services Agency (HCSSA) nurse may delegate to an attendant under his supervision, per BON rules. A member with a skilled task need may use an attendant with delegated tasks if a practitioner or RN delegates the skilled task required to meet the member's needs.
If the member does not have a skilled task need for the delivery of flexible family support services (FFSS), he does not have a need for an attendant with delegated tasks. If the member or primary caregiver requests the use of an attendant with delegated tasks, but the service coordinator or the HCSSA provider determines the use of this provider type places the individual's health and welfare at risk, the service coordinator should not authorize an attendant with delegated tasks to deliver respite, unless determined appropriate by the member's physician.
If a member or his legally authorized representative (LAR) employs an attendant under the Consumer Directed Services (CDS) option, delegation of certain tasks is not required under the CDS option. Form 1585, Acknowledgment of Responsibility for Exemption from Nursing Licensure for Certain Services Delivered through CDS, outlines what services cannot be delegated, such as specific tasks involved in the implementation of the care plan that require professional nursing judgment or intervention. If the member or his LAR is directing the member's services, he must sign Form 1585, acknowledging responsibility for the training and oversight of an attendant.
Flexible family support services (FFSS) may be used only when the primary caregiver is working, attending school or participating in job training, and are delivered in a setting where the delivery of similar supports is not already required or included as part of the service. For this reason, the service coordinator may not authorize FFSS during the same time period the individual receives personal care services or Community First Choice.
42 Code of Federal Regulations §446.301(b)(1)(ii) requires that Medically Dependent Children Program services, including FFSS, may not be provided to a member who is admitted to a hospital, or is a resident of a nursing facility or intermediate care facility for individuals with an intellectual disability or related conditions.
The service coordinator may not authorize FFSS during the member's school hours in primary or secondary educational settings.
control the environment in which they live.
A member must exhaust any applicable Medicare, Medicaid or other third-party resources for durable medical equipment and adaptive aids before adaptive aids available under the Medically Dependent Children Program are authorized. A member may take an adaptive aid to an out-of-home respite facility for use while residing there.
The managed care organization (MCO) may authorize bids for adaptive aids, such as vehicle modifications, as applicable. The cost of these bids does not count against the member's annual limit for adaptive aids.
If the cost of a requested adaptive aid exceeds the service limit, the MCO may approve the request only if the member agrees to pay any costs that are in excess of the service limit. The MCO must document the member's agreement to pay these costs in the member's case file. Documentation must include, at a minimum, a description of the adaptive aid, rationale for exceeding the service limit, the cost incurred to the MCO, the cost incurred to the member, the member's signature, the date of the member's agreement, and signature of the provider. Documentation must be on file prior to the MCO authorizing an adaptive aid that exceeds the service limit.
A minor home modification is a physical modification to a member's residence necessary to prevent institutionalization or support de-institutionalization. Minor home modifications are necessary to ensure the health, welfare and safety of the member or to enable the member to function with greater independence in his or her home. If a home modification is requested and the member or his legally authorized representative (LAR) does not own the home in which the modification will take place, the member, LAR, or the service coordinator must obtain written agreement from the homeowner before a modification is authorized. STAR Kids managed care organizations may not require minor home modification providers to obtain a denial or explanation of benefits from a member's primary insurance before seeking reimbursement for minor home modifications services.
The minor home modification lifetime limit is $7,500. The service coordinator may authorize up to $300 per the individual service plan (ISP) period for maintenance or repairs of minor home modifications previously approved and reimbursed with waiver funds. The service coordinator does not include $300 maintenance and repair limit as part of the $7,500 lifetime limit. The amount paid for a modification or for the repair of a minor home modification must be documented on Form 2416, Minor Home Modifications and Adaptive Aids Service Authorization, and retained in the member's case file. A minor home modification must not create a new structure or add square footage to the home.
The managed care organization (MCO) may authorize bids for minor home modifications, as applicable. The cost of these bids does not count against the member's lifetime limit for minor home modifications.
modifications related to the approved installation or modification of ramps, doorways or bathroom facilities.
have a minimum one-year warranty.
Minor home modifications do not include the use of deluxe materials, such as granite, marble or high-end fixtures.
If a request for repair or maintenance to a minor home modification is not covered by the provider's warranty, the service coordinator may authorize up to $300 for the member or his legally authorized representative to select a provider contracted with the STAR Kids MCO. The $300 limit is available per the member’s ISP year for maintenance and repair and is not included in the $7,500 lifetime minor home modification service limit.
If the cost of a requested minor home modification exceeds the service limit, the MCO may approve the request only if the member agrees to pay any costs that are in excess of the service limit. The MCO must document the member's agreement to pay these costs in the member's case file. Documentation must include, at a minimum, a description of the home modification, rationale for exceeding the service limit, the cost incurred to the MCO, the cost incurred to the member, the member's signature, the date of the member's agreement, and signature of the provider. Documentation must be on file prior to the MCO authorizing a home modification that exceeds the service limit.
need belongings moved from the NF to the new residence.
site preparation services, such as pest eradication, allergen control or a one-time cleaning before occupancy.
The applicant or member selects a TAS agency from the list of contracted agencies. The STAR Kids MCO may require the applicant, member, or legally authorized representative to attest that the items requested for TAS are the basic, essential needs required to move into the community, and they agree the TAS agency selected is authorized to make the purchases for them. The service coordinator must explain to the applicant or member that the service will not be authorized until the applicant or member is determined eligible for MDCP waiver services, and notified in writing that he or she is eligible. The service coordinator must contact the applicant/member or applicant's/member's representative before certification to verify the applicant or member has made arrangements for relocating to the community and has finalized a projected discharge date. The amount of TAS a member received must be documented on Form 2416, Minor Home Modifications and Adaptive Aids Service Authorization.
The service coordinator may authorize Transition Assistance Services (TAS) to pay deposits, which include security deposits for residential leases and household utilities, including basic telephone service. Security deposits or utility deposits must be in the applicant's or member's name.
Residential Leases – A security deposit is a one-time expense and the amount may be no more than the equivalent of two months' rent. The service coordinator must not authorize TAS to pay rent. TAS may be accessed to pay for pet deposits only if the pet is the applicant's or member's service animal.
Household Utilities – TAS may be used to pay for utility deposits to establish accounts in the applicant's or member's name or to pay for arrears on previous utilities if the account is in the applicant's or member's name and he or she will not be able to get the utilities unless the previous balance is paid. TAS cannot be used for payment toward utilities. TAS may be used to pay for a telephone since it is a basic need, but may not be used to purchase minutes or services for the telephone. The managed care organization (MCO) may have internal policies regarding the type of telephone that may be authorized.
TAS funds can be used to pay for initial setup or reconnection fees for propane or butane service, including the minimal supply of fuel if the utility company requires a minimal supply of fuel to be delivered during the initial or reconnection service call.
Essential Furnishings – TAS household items that, if absent, would pose a barrier to the applicant's or member's transition into the community. Essential furnishings purchased with TAS funds may include furniture, appliances, housewares and cleaning supplies.
Furniture – TAS can be used to purchase furniture such as a bed, recliner or dinette if the applicant's or member's place of residence does not have the needed furniture and the absence of the item prevents the transition into the community.
Appliances – TAS can be used to purchase appliances such as a refrigerator, stove, washer, dryer, microwave oven, electric can opener, coffee pot or toaster if the applicant or member identifies these appliances as needed items.
Housewares – TAS can be used to purchase basic housewares such as pots, pans, dishes, silverware, cooking utensils, linens, towels, a clock and other small items required to set up the household.
Cleaning Supplies – TAS can be used to purchase basic cleaning supplies such as a mop, broom, vacuum, brushes, soaps and cleaning agents required for the household.
Other – TAS can be used to purchase any special request from the applicant or member not included in the general list that meets the criteria as a basic essential furnishing to transition into the community, if approved by the STAR Kids MCO.
Transition Assistance Services (TAS) can be used to pay for moving expenses, which may include the cost of moving the applicant's or member's belongings from the nursing facility to the community residence, or delivery charges on approved TAS items.
Moving expenses may include the cost of a designated mover or retail store to deliver or move furniture, major appliances and other items approved as required for relocation to the community. Moving expenses do not include the cost of transporting the applicant or member from the nursing facility to his or her residence in the community.
Transition Assistance Services (TAS) can be used to pay for preparing the applicant's or member's place of residence for occupancy if the current condition of the residence prevents the applicant's or member's transition from the nursing facility. Site preparation purchased with TAS funds may include one-time expenses such as pest eradication, allergen control and residential cleaning.
Pest Eradication – TAS can be used if the residence has been unattended and is in need of some type of extermination.
Allergen Control – TAS can be used if the residence has been unattended or the applicant or individual is moving into a place that poses a respiratory health problem.
One-time Cleaning – TAS can be used if the applicant's or member's residence has been unattended or the applicant or member is moving into a private home or apartment where pre-move-in cleaning should not be expected. For example, a family friend has an empty house available but cannot provide the cleaning.
any diversional or recreational items or services, including televisions, video players or recorders, movies, games, computers, cable TV, satellite TV, exercise equipment, vehicles or other modes of transportation.
TAS does not include any items or services that may be accessed through other MDCP services, such as adaptive aids or minor home modifications. TAS is only available to applicants or members who are discharged from a nursing facility and require TAS to set up a household.
The Transition Assistance Services (TAS) agency accepts all members referred by the managed care organization (MCO). Upon receipt of the authorization, the TAS agency must review the authorization carefully and contact the MCO if there are any questions regarding the authorization. This contact must occur by the next business day of receipt of the forms, and before any TAS purchase is made. The MCO contacts the member or his legally authorized representative, if necessary, to discuss the item in question. The MCO provides a revised TAS authorization within two business days if it clarifies an item is authorized or approves a change to the authorization.
The TAS agency purchases the authorized items/services and arranges and pays for the delivery of the purchased items, if applicable. The TAS agency only purchases services or items within the authorization made by the MCO. The TAS agency contacts the member or member's authorized representative, if necessary, to coordinate service delivery. The TAS agency delivers the authorized services by the completion date recorded on the TAS authorization form. The agency provides a copy of the purchase receipts and any original product warranty information to the member. The TAS agency maintains the original purchase receipts, including sales tax, delivery or installation charges.
The TAS agency orally notifies the MCO of a delivery delay before the completion due date and documents the delay. The agency also contacts the member or the member's representative by the completion date to confirm that all authorized TAS services were delivered.
The managed care organization (MCO) monitors the member within three business days following the discharge date to assure the delivery of all services and items authorized through the Transition Assistance Services (TAS) agency. If the member reports that any items have not been delivered or services not performed, the MCO contacts the TAS agency by telephone and follows up in writing. Written documentation must be maintained in the member’s case record.
While the managed care organization (MCO) makes every effort to confirm the member has definite plans to leave the facility, there may be situations in which the member changes his mind or has a change in health making it impossible for him to relocate to the community as planned. In this situation, the MCO notifies the Transition Assistance Services (TAS) agency that the member is no longer moving and no further items are to be purchased.
The TAS agency must attempt to return any item(s) purchased on behalf of the individual and collect a refund for the amount of the purchase. The TAS agency also must attempt to recoup security, utility and other deposits paid on behalf of the individual. Failure to leave a facility does not count against a member's lifetime TAS limit.
If the TAS agency is unsuccessful in returning the item(s) for the amount of monies paid, or the deposits paid on behalf of the individual cannot be recouped, the TAS agency is entitled to the cost of the item(s) and/or reimbursement for deposits paid, not to exceed the authorized amount. The TAS agency sends the MCO written notice stating the item(s) could not be returned or the deposits could not be recouped. The MCO contacts a local charity to donate the items and makes arrangements for pick up. The charity must serve individuals whose needs are similar to those of the individual for whom the items were purchased or must be dedicated to assisting the individual to establish a home.
If the TAS agency is able to return the item(s) or receives the deposits back, the TAS agency is not entitled to reimbursement. If the TAS agency recoups part of the monies paid, the TAS agency is entitled to the costs of the item(s) or deposits less any monies recouped. Any claims that had been filed and paid for the item(s) or deposits would need to be adjusted by the TAS agency to pay the monies back to the MCO.
If a service has already been provided (for example, pest eradication), the TAS agency is entitled to the cost of the service, not to exceed the authorized amount.
If the member is only in the community for a few days and returns to the nursing facility, the member keeps the item(s) purchased through TAS.
Senate Bill 45, 83rd Legislature, Regular Session, 2013, required all Medicaid waivers offer employment assistance (EA) and supported employment (SE). Employment services are intended to assist members to find employment and maintain employment. Employment services available for members in the Medically Dependent Children Program are EA and SE. STAR Kids managed care organizations may not require SE or EA providers to obtain a denial or explanation of benefits from a member's primary insurance before seeking reimbursement for SE or EA services.
contacting a prospective employer on behalf of a member and negotiating the member's employment.
For any MDCP member, the service coordinator must ensure and document that employment services are not available to the member from the member's school district or other available community resource before authorizing waiver EA services.
The service coordinator refers the member to the Texas Workforce Commission (TWC) within 30 days of meeting with a member and identifying an interest in obtaining employment. The service coordinator should contact the local TWC office to identify the referral process used by that office. Local TWC offices may be located at http://www.twc.state.tx.us/directory-workforce-solutions-offices-services-0#workforceServices.
A member who has been referred for TWC or contacted TWC himself is not eligible to receive EA through MDCP until TWC has developed the Individualized Plan of Employment (IPE) and the member has signed it, or until the member is denied services through TWC. If a member refuses to contact TWC, he or she may not receive waiver-funded EA. If a member is denied assistance through TWC, EA through MDCP may be authorized.
If the member has exhausted TWC services or been determined ineligible for TWC services, the service coordinator authorizes a minimum of 10 hours for employment on the member's individual service plan (ISP). Employment assistance can be authorized up to 180 days. The member or provider may request more hours for EA, if needed, and funds are available in the member's MDCP budget.
Contact information for the member's service coordinator.
If the VRC determines that TWC is not the appropriate resource to meet the member's needs and does not take an application for services, documentation of this decision in the member's record serves as sufficient evidence that TWC is not available and the member is eligible to receive waiver-funded employment assistance.
The notification letter indicating TWC is completed.
If TWC has not notified the member of an eligibility decision within 60 days of the initial TWC appointment, the member's service coordinator will attempt to contact the assigned TWC VRC to determine the status of the application and document the contact in the narrative notes.
The member's service coordinator will ensure that communication is maintained with the assigned TWC VRC regarding waiver-funded services provided between the Vocational Rehabilitation (VR) referral and the "start date" of TWC, as defined in the individual's TWC VR IPE.
review the long term services and supports listed on the TWC IPE and if any of those services and supports are available through the waiver, incorporate them in a revision to the member's service plan prior to the end of TWC services.
The member's provider must begin providing or subcontracting for those services and supports approved in the member's service plan without a gap between the provision of TWC and waiver services.
Six months of paid or unpaid experience providing services to people with disabilities.
One year of paid or unpaid experience providing services to people with disabilities.
Two years of paid or unpaid experience providing services to people with disabilities.
Under the CDS option, the provider cannot be the member's legal guardian or the spouse of the legal guardian.
Supported employment (SE) services provide assistance to help a member receiving Medically Dependent Children Program (MDCP) services sustain competitive employment or self-employment.
ensuring members earn at least minimum wage, if not self-employed.
for which a member is compensated at or above the minimum wage, but not less than the customary wage and level of benefits paid by the employer for the same or similar work performed by individuals without disabilities.
a mobile crew of people with disabilities work in the community.
actively markets a service or product to potential customers.
SE may only be authorized through the MDCP waiver if documentation is maintained in the member's record that the service is not available to the member under a program funded under the Individuals with Disabilities Education Act (20 U.S.C. §1401 et seq.) or the Texas Workforce Commission.
The service coordinator coordinates with the Texas Workforce Commission (TWC) and the local school districts, seeking third party resources before using Medically Dependent Children Program employment services, including school districts.
monitoring whether the member and family are satisfied with the employment supports.
Under CDS, the provider cannot be the member's legal guardian or the spouse of the legal guardian.

References: §441
 § 1902
 §531
 §225
 §363
 §363
 §441
 §446
 §1401