Source: https://hhs.texas.gov/laws-regulations/handbooks/community-living-assistance-support-services-provider-manual/class-pm-section-2000-case-management-agency-cma
Timestamp: 2018-02-24 11:36:55
Document Index: 782188205

Matched Legal Cases: ['§48', '§45', '§45', '§45', '§45', '§45', '§45', '§45', '§45', '§45', '§45', '§45', '§441']

CLASS-PM, Section 2000, Case Management Agency (CMA) | Texas Health and Human Services
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2100 Case Management Responsibilities
Case management services are provided to all individuals receiving Community Living Assistance and Support Services (CLASS) program and Community First Choice (CFC) Personal Assistance Services/Habilitation (PAS/HAB) services in the CLASS program. Individuals must select a CMA with a valid provider agreement in the catchment area in which the individual lives. Individuals who receive services in the CLASS program may request to transfer to another CMA at any time.
As outlined in this section, the CMA is required to provide the following case management services on an ongoing basis:
provide technical assistance to individuals using the Consumer Directed Services (CDS) service delivery option when completing Form 3596, PAS/Habilitation Plan - CLASS/DBMD/CFC ;
CLASS program services, as a whole, enhance an individual's integration into the community and prevent admission to an institution while maintaining and improving independent functioning.
2110 Base of Operation
Revision 11-3; Effective November 18, 2011
CLASS program providers must have a base of operation that includes a physical location and normal operating hours in each geographic catchment area for which they have a contract to provide CLASS program services.
maintain personnel records for personnel who provide CLASS program services to individuals served in the catchment area;
2120 CMA Staff Training Requirement
2121 Initial Training for Staff with Direct Contact
Direct contact for the purposes of this manual means face to face contact. Upon hire, all CMA staff whose job functions might involve direct contact a minimum of one time per calendar year with individuals receiving Community Living Assistance and Support Services (CLASS) must complete one of the following within 60 calendar days of the employee beginning to provide CLASS program services:
In-person CLASS provider training provided by the Texas Health and Human Services (HHSC).
Training developed by CMA that includes, at a minimum:
CMA's complaints process;
The CMA could choose to conduct training at its location to meet the above requirements within 60 days of hiring the service provider. CMA staff who develop the curriculum used for initial training must have attended and successfully completed the CLASS Provider Training provided by HHSC. The CMA must have a record to verify that the trainer has attended the CLASS Provider Training. The CMA may choose to send new employees to CLASS Provider Training at the next opportunity offered by HHSC to further reinforce training provided by the CMA.
written documentation of completion of CMA's training that includes:
If a CMA develops curriculum to meet CLASS training requirements, the curriculum and training materials used must be maintained by CMA and be available to HHS employees during a contract monitoring review.
2122 Initial and Annual Training for All CMA Staff
All CMA staff must complete the training described below within 60 calendar days of employment and at least every 12 months thereafter.
Abuse, Neglect and Exploitation (ANE)
review of the statute on ANE at Human Resources Code, Chapter 48, §48.002 (2, 3 and 4);
how to report abuse and neglect to DFPS at https://www.dfps.state.tx.us/Contact_us/report_abuse.asp.
information about the rights of the individual who receives CLASS services as outlined in the Your Rights in these Community Programs; and
review of CLASS rules in Chapter 45, Subchapter C, §45.301 and §45.302 concerning the Rights and Responsibilities of an Individual.
If a CMA develops curriculum to meet CLASS training requirements, the curriculum and training materials used must be maintained by CMA and available to HHSC employees during a contract monitoring review.
2123 CMA Staff Training for Person-Centered Planning
CMA staff responsible for completing Form 8606, Individual Program Plan (IPP) and Form 3629 Individual Program Plan Addendum (IPP-A) must complete person-centered service planning training approved by HHSC depending upon the staff date of hire. If the staff person was hired on or before June 1, 2015, the staff must complete the training by June 1, 2017. If the staff person was hired after June 1, 2015, the staff person must complete the training within two years after the hire date.
2200 Eligibility
The case manager is responsible for verifying the individual's eligibility for the CLASS program by ensuring the following criteria are met.
The individual is financially eligible for Medicaid because the individual receives Supplemental Security Income (SSI) cash benefits or is determined by HHS to be financially eligible for Medicaid.
The individual has a qualifying adaptive behavior level of II, III, or IV (i.e., moderate to extreme deficits in adaptive behavior) obtained by administering a standardized assessment of adaptive behavior.
The individual requires and receives:
at least one CLASS service per month; and
one CLASS service per year (monthly monitoring of services by a case manager meets this annual requirement).
The individual has an Individual Plan of Care (IPC) cost for CLASS services at or below $114,736.07.
The CMA must verify Medicaid eligibility each month by monitoring the Medicaid Eligibility Service Authorization Verification (MESAV) system. The Medicaid eligibility must verify the individual is eligible in the month that is being checked. Documentation of this monthly verification of eligibility for Medicaid must be maintained by the CMA and available for review during contract monitoring visits. If the CMA receives notice of an individual's impending loss of Medicaid eligibility, the CMA must work proactively with the individual/legally authorized representative (LAR) to ensure Medicaid eligibility is re-established as soon as possible. For individuals who lose Medicaid eligibility, the CMA must offer direct assistance to the individual/LAR as necessary to help the individual re-establish eligibility. The CMA must follow up with the individual/LAR at least every two weeks and document progress toward completion of necessary steps until Medicaid eligibility is re-established or the individual is terminated from the CLASS program.
Program services may be terminated if the individual does not meet any eligibility criteria as outlined in Title 40 of the Texas Administrative Code (TAC) §45.406. See Section 2400, Denial, Reduction, Suspension and Termination, for more information on termination of services.
2300 Service Planning
The case manager facilitates Service Planning Team (SPT) meetings. The SPT process uses a person-centered planning processes to develop a plan for the provision of supports and services necessary for the individual's functioning and to maintain integration in the community. After all requirements for eligibility are met, and at least annually thereafter, the case manager, the applicant/individual/legally authorized representative (LAR), DSA representative(s) (as defined in Section 3300, Service Planning), and other people requested by the applicant/individual/LAR meet to develop a proposed Form 3621, CLASS/CFC – Individual Plan of Care (IPC). The case manager must use the SPT notes in conjunction with Form 3629, IPP-A to document use of person-centered planning processes.
The case manager, using the discovery process as the basis for collecting information, develops the person-centered plan with the individual, legally authorized representative (LAR), the CMA, DSA representative, and others, as requested by the individual or LAR.
information about the person gained from engaging in conversations with the individual, LAR and those who know the individual best, such as a provider staff, caregiver, family member and friend;
utilizing the Planning Alternative Tomorrows with Hope (PATH) method;
utilizing methods taught by The Learning Community for Person Centered Practices (TLCPCP), which occur with the support of a group of people chosen by the individual (and the legally authorized representative (LAR) on the individual's behalf).
The person-centered planning process:
identifies and document the individual’s current and preferred living arrangement;
determines the service needs of an individual;
documents the individual’s preferences for when to receive CLASS services;
Additional guidance and information about person-centered planning can be found on the HHSC website.
Meetings of the SPT to develop the enrollment IPC and the renewal IPC should be held in the individual’s own home or family home whenever possible. If it is not possible, the SPT must document why the meeting could not be held in the individual’s home. While individuals or their LAR may request the case manager meet in locations other than their own home/family home, case managers should remind them that meeting in the home allows the SPT the opportunity to determine if other needs of the individual may be met by through CLASS or CFC services. The enrollment and renewal IPC must be signed in person by the SPT.
SPT activities to revise a current IPC may occur via conference call in lieu of a face-to-face meeting. Revisions of the current service plan may be signed by facsimile.
The case manager is required to ensure that the SPT develops a transportation plan if habilitation transportation is included on the IPC. Information on completing Form 3598, Individual Transportation Plan is available in the instructions.
the type of CLASS program services to be provided to the individual;
the number of units of each CLASS program service;
the number of units of each CFC service (except support management)
the estimated annual cost of all CLASS program and CFC services; and
other services or supports to be provided to the individual through sources other than the CLASS program.
As part of the service planning process, the SPT will also develop an IPP on Form 8606, Individual Program Plan (IPP).
An IPP is needed for each CLASS program service listed on the proposed IPC. Each IPP describes:
CLASS program services to be provided;
frequency of service provisions;
title of person responsible for goals and objectives;
justification for services based on needs identified by the SPT;
duration of services; and
support services provided through non-waiver resources.
The IPP-A and SPT notes are created by the case manager during the SPT meeting to document use of person-centered planning processes. The IPP-A and SPT notes summarize the outcome of the meeting and must be included with the IPP-A to provide additional information. The SPT notes must include, at a minimum:
each service being requested by the SPT;
planned service schedules for each service requested;
units/amount of each service requested; and
signature and date of each SPT member present at the meeting.
If the individual requests a therapeutic service (e.g., occupational therapy, physical therapy, speech and language pathology, behavioral support, audiology, dietary service, auditory enhancement training or any specialized therapy), the case manager must initiate Form 8606-A, Therapy Justifications – Attachment to IPP, based on the deliberations of the SPT. The case manager must coordinate the completion of Attachment A with the appropriate professional. Since this professional is employed by, or contracts with, the DSA, assistance from the DSA is vital to ensure the case manager performs this function. The signature date of the professional on Attachment A may precede the effective date of the IPC that identifies the individual’s need for the service or continuation of the need for the service by no more than 120 days.
The case manager is responsible for initiating revisions to the individual's IPC and IPP-A as determined necessary throughout each plan year. The case manager will submit all proposed IPCs and revised IPP-A to HHSC.
On an ongoing basis, the case manager must assist individuals in gaining access to needed CLASS services and other services and supports, including medical, social, and educational resources, regardless of the funding source for the services and supports.
All requests from HHSC related to the UR process must be submitted within the period outlined in Section 5000.
The CMA is responsible for providing a copy of the following documentation to all SPT members within 10 business days from HHSC authorization, including the financial management services agency (FMSA), if the individual receives a service through the Consumer Directed Services option:
authorized Form 3621, CLASS/CFC — Individual Plan of Care;
Form 3629, Individual Program Plan Addendum;
Form 8606, Individual Program Plan (IPP);
SPT notes;
Form 8606-A, Therapy Justifications — Attachment to IPP, if applicable;
Form 3660, Request for Adaptive Aids, Medical Supplies, Minor Home Modifications or Dental Services/Sedation, if applicable; and
additional documentation as agreed upon by the SPT.
At the time an applicant receives a written offer of a CLASS program vacancy from HHSC, the applicant must select a CMA within 30 calendar days after the date of the written offer. HHSC notifies the selected CMA the applicant has chosen the agency to provide case management services. According to the Selection Determination document the CMA then completes the following:
Form 3657, Pre-Enrollment Assessment;
Form 8507, Understanding Program Eligibility - CLASS/DBMD;
assists the applicant with the application process for Medicaid eligibility, if needed; and
provides general information regarding the CLASS Medicaid waiver program to CLASS applicants.
The case manager must provide the applicant/individual the CLASS Program brochures in English or Spanish, as appropriate.
The case manager should take advantage of this opportunity to describe the person-centered planning process, as described in Section 2300, that will be used to develop the IPP-A.
Upon notification that the applicant has selected the CMA, a case manager must be assigned to the applicant. The CMA must have a written process that ensures case managers are or can readily become familiar with individuals to whom they are not ordinarily assigned, but to whom they may be required to provide case management.
The case manager must complete the following functions within 14 calendar days of the CMA's receipt of the Selection Determination document from HHSC:
provide applicant/legally authorized representative (LAR) with name and contact information, including an alternate contact in case of absence of the case manager;
conduct an initial face-to-face, in-home visit with the applicant/LAR that must include providing an oral and written explanation of:
CLASS program services;
CFC services available in the CLASS program through the Medicaid State Plan;
CFC personal assistance services/habilitation (CFC PAS/HAB), which provides all the activities of habilitation, except habilitation transportation services;
CFC emergency response services (CFC ERS), which is provided as a CFC service;
CFC support management;
the eligibility requirements for CLASS Program services and CFC services using Form 8507, Understanding Program Eligibility- CLASS/DBMD;
the mandatory participation requirements;
the CDS option;
information about cognitive rehabilitation therapy (CRT) and assistance for the individual to obtain a neurobehavioral or neuropsychological assessment and plan of care from a qualified professional using Medicaid State Plan, if appropriate;
Form 8601, Verification of Freedom of Choice, specifying choice of CLASS services instead of institutional services in an Intermediate Care Facilities for Individuals with an Intellectual Disability or Related Conditions (ICF/IID);
provide information regarding voter registration, if the applicant is age 18 or older;
if the applicant is transferring from an institution, provide information regarding Transition Assistance Services (TAS):
ensuring the proper information is included on Form 8604, Transition Assistance Services (TAS) Assessment and Authorization;
sending the completed form to HHSC for authorization with the proposed enrollment IPC;
sending the authorized form to the TAS provider; and
including the TAS and the monetary amount authorized by HHSC on the individual's proposed enrollment IPC;
provide an oral and written explanation to the applicant/LAR describing that the DSA may be requested to provide CFC PAS/HAB or out-of-home respite in a camp while the individual is temporarily staying outside the catchment area in which the individual resides, but within the state of Texas, as described in 40 TAC §45.702 , including that the DSA may accept or decline the request;
provide the following information regarding required use of the Electronic Visit Verification (EVV):
EVV helps HHSC make sure authorized services are received.
EVV is mandatory for all DSAs and individuals receiving services from a CFC PAS/HAB services provider, unless the individual receives services through the CDS
The CFC PAS/HAB services provider will need the applicant’s permission to use the telephone to call a toll-free number at the start and at the end of work.
If the applicant does not have a telephone or does not want the CFC PAS/HAB services provider to use his telephone, a fixed verification device can be placed in the home, which is used only to verify the CFC PAS/HAB services provider’s start and end of work.
EVV is mandatory for all DSAs and applicants who will be receiving services from a CFC PAS/HAB services provider, unless the applicant elects to receive services through the CDS option.
If the applicant has additional questions, the case manager refers him to the selected DSA or FMSA for additional information on how EVV works;
complete Form 3657; and
verify residency to ensure the applicant lives in his own or family home that is located within the catchment area for which the CMA has a current Community Services Contract (Provider Agreement), to provide CLASS program services.
The case manager must complete the following functions within two business days following the initial face-to-face assessment:
evaluate the applicant's need for CFC PAS/HAB services;
assist with Medicaid eligibility processes, as necessary;
verify the individual is not enrolled in another 1915(c) Medicaid waiver program or any other mutually exclusive services or programs (See Appendix III, Mutually Exclusive Services); and
provide the DSA with a completed Form 3657.
Within 30 calendar days of notification by the DSA of HHSC approval of diagnostic/functional eligibility for an individual as identified on Form 8578, Intellectual Disability/Related Condition Assessment, the case manager must convene the SPT to develop the enrollment IPC, Form 3621, CLASS/CFC – Individual Plan of Care (IPC) and Form 3629, Individual Program Plan Addendum using a person-centered planning process as described in Section 2300.
The SPT must include, at a minimum, the applicant/LAR, case manager and a DSA representative. The individual or LAR may request the SPT include professionals who are qualified by certification or licensure, or training and experience in the habilitation needs of people with related conditions, or directly involved in the delivery of services and supports to the individual. The SPT may include any other people requested by the individual/LAR. The SPT must make every effort to accommodate these requests by the individual/LAR.
Within 10 business days of HHSC transmission of the authorized enrollment IPC, as evidenced by the fax transmittal date on the documents, the case manager must provide copies of the authorized Form 3621, Form 8606, Form 3629, the SPT notes, Form 8606-A (if applicable), Form 3660 (if applicable), and additional documentation as agreed upon by the SPT to all members of the SPT. The case manager must provide copies of this documentation to any additional CLASS service providers (FMSA, Continued Family Services [CFS], and Support Family Services [SFS]), as necessary. The case manager must maintain documentation of transmission of all necessary documents.
Form 1351, Request to Withdraw from the CLASS Application Process
Form 3596, PAS/Habilitation Plan — CLASS/DBMD/CFC
Form 3621, CLASS/CFC — Individual Plan of Care
Form 3623, Approval of Application for CLASS
Form 3625, CLASS/CFC — Documentation of Services Delivered
Form 3657, Pre-Enrollment Assessment
Form 4800-D, DADS Fair Hearing Request Summary
Form 8001, Medicaid Estate Recovery Program Receipt Acknowledgement
Form 8601, Verification of Freedom of Choice
Form H1010, Texas Works Application for Assistance – Your Texas Benefits
Submission Standard — Enrollment
The following submission standards apply when submitting enrollment paperwork to HHSC:
Form 3598, Individual Transportation Plan (only include if this specific service has been proposed as part of an enrollment IPC)
Form 3660, Request for Adaptive Aids, Medical Supplies, Minor Home Modifications or Dental Services/Sedation (only include if this specific service has been proposed as part of an enrollment IPC)
Form 3849-A, Specifications for Adaptive Aids/Medical Supplies/Minor Home Modifications, including bids (only include if funding for specifications has been proposed as part of an enrollment IPC)
Form 8604, Transition Assistance Services (TAS) Assessment and Authorization (only include if this specific service has been proposed as part of an enrollment/renewal IPC)
Form 8606-A, Therapy Justifications – Attachment to IPP (only include if this specific service has been proposed as part of an enrollment IPC)
The following submission standards apply when submitting paperwork containing funding proposals for pre-enrollment efforts to HHSC:
Form 3625, CLASS/CFC – Documentation of Services Delivered;
Form 3657, Pre-Enrollment Assessment (partial assessment fee); or
Form 3621, CLASS/CFC – Individual Plan of Care (full assessment fee)
2320 Renewal
The case manager must complete the following functions no less than 30 calendar days and no more than 90 calendar days before the end of the current IPC year:
provide an oral and written explanation to the individual/legally authorized representative (LAR) describing that the DSA) may be requested to provide CFC PAS/HAB or out-of-home respite in a camp while the individual is temporarily staying outside the catchment area in which the individual resides, but within the state of Texas. The service period cannot exceed 60 consecutive days. The case manager must provide the information contained in 40 TAC §45.702 regarding this option, including the DSA option to accept or decline the individual’s request;
provide information about cognitive rehabilitation therapy (CRT) and assistance for the individual to obtain a neurobehavioral or neuropsychological assessment and plan of care from a qualified professional using Medicaid State Plan, if appropriate;
provide Form 8601, Verification of Freedom of Choice, specifying the individual’s choice to continue to receive CLASS services instead of ICF/IID and obtain the individual’s signature;
convene a SPT to develop using person-centered planning processes:
a renewal IPC – the CLASS program services on the proposed renewal IPC must meet the following standards:
are the most appropriate type and amount of CLASS program services to meet the individual's needs; and
the IPPA; and
a CFC PAS/Habilitation Plan;
submit to HHS:
Form 3621, CLASS/CFC — Individual Plan of Care;
Form 8606, Individual Program Plan (IPP); the SPT notes;
additional documentation as agreed upon by the SPT for review; and
submit a copy of the proposed renewal IPC to the FMSA, if applicable.
Within 10 business days of HHSC transmission of the authorized renewal IPC, as evidenced by the fax transmittal date on the documents, the case manager must provide copies of the authorized Form 3621, Form 8606, Form 3629, the SPT notes, Form 8606-A (if applicable), Form 3660 (if applicable), and additional documentation as agreed upon by the SPT to all members of the SPT. The case manager must provide copies of this documentation to any additional CLASS service providers (FMSA, Continued Family Services [CFS], and Support Family Services [SFS]) as necessary. The case manager must maintain documentation of transmission of all necessary documents.
The CMA must electronically access MESAV to verify that the services authorized on the renewal IPC are consistent with those authorized in MESAV by HHSC.
At HHSCs request, the CMA must submit additional documentation supporting the proposed renewal IPC to HHSC within 10 calendar days after HHSC requests it. The date of HHSC’s request for additional documentation is determined by the date on Form 2067, Case Information, faxed to the CMA that requests the additional documentation.
If HHSC notifies the CMA of the denial or reduction of a CLASS program or CFC service, see Section 2400, Denial, Reduction, Suspension and Termination.
Form 8578, Intellectual Disability/Related Condition Assessment (Pages 1 and 3)
The following submission standards apply when submitting renewal paperwork to DADS:
Form 3598, Individual Transportation Plan (only include if this specific service has been proposed as part of a renewal IPC)
Form 3660, Request for Adaptive Aids, Medical Supplies, Minor Home Modifications or Dental Services/Sedation (only include if this specific service has been proposed as part of a renewal IPC)
Form 3849-A, Specifications for Adaptive Aids/Medical Supplies/Minor Home Modifications, including bids (only include Form 3849-A if funding for specifications has been proposed as part of a renewal IPC)
Form 8578, Intellectual Disability/Related Condition Assessment (ID/RC)
Form 8606-A, Therapy Justifications – Attachment to IPP (only include if this specific service has been proposed as part of a renewal IPC)
2330 Revision
When the case manager is notified of a needed revision to the IPC, the case manager must ensure:
a proposed IPC revision includes:
an IPP for each service revised on the proposed IPC;
a revised Form 3629, Individual Program Plan Addendum, if applicable; and
a revised PAS/Habilitation Plan - CLASS/DBMD/CFC, if the individual’s needs have changed substantially since the most recent revision;
the CLASS program services on the proposed IPC revision must meet the following standards:
are the most appropriate type and amount of CLASS program services to meet the individual's needs;
the proposed IPC, IPP-A, IPPs, and PAS/Habilitation Plan - CLASS/DBMD/CFC are submitted to HHSC for review at least 30 calendar days before the effective date proposed by the SPT.
At the request of HHSC, the CMA must submit additional documentation supporting the proposed IPC revision to HHSC within 10 calendar days after HHSC requests it. The date of HHSC’s request for additional documentation is determined by the date on Form 2067, Case Information, faxed to the CMA that requests the additional documentation.
Within five business days of HHSC’s transmission of the authorized IPC, as evidenced by the fax transmittal date on the documents, the case manager must provide copies of the following to all members of the SPT:
Form 3629, Individual Program Plan Addendum,
the SPT notes;
The case manager must also provide copies of the above documentation within five business days of HHSC’s transmission of the authorized IPC to any additional CLASS service providers (FMSA, CFS, and SFS), as necessary. The case manager must maintain documentation of transmission of all necessary documents.
The following submission standards apply when submitting revision paperwork to HHSC:
Form 3596, PAS/Habilitation Plan – CLASS/DBMD/CFC (only include if this specific service has been proposed as part of an IPC revision marked "New" or "Change" in Field 16a on Form 3621)
Form 3598, Individual Transportation Plan (only include if this specific service has been proposed as part of an IPC revision marked "New" or "Change" in Field 16a on Form 3621)
Form 3660, Request for Adaptive Aids, Medical Supplies, Minor Home Modifications or Dental Services/Sedation (only include if this specific service has been proposed as part of an IPC revision marked "New" or "Change" in Field 16a on Form 3621)
Form 3849-A, Specifications for Adaptive Aids/Medical Supplies/Minor Home Modifications, including bids (only include if funding for specifications has been proposed as part of an IPC revision)
Form 8606, Individual Program Plan (IPP) (only include if this specific service has been proposed as part of an IPC revision marked "New" or "Change" in Field 16a on Form 3621)
Form 8606-A, Therapy Justifications – Attachment to IPP (only include if this specific service has been proposed as part of an IPC revision marked "New" or "Change" in Field 16a on Form 3621)
2331 Immediate Jeopardy of CLASS Individual
When the CMA receives written documentation from the DSA indicating the DSA provided CFC PAS/HAB, respite, nursing, dental services or an adaptive aid that is not included on the individual's IPC in response to a situation of the individual's immediate jeopardy, the case manager must complete and submit the following to HHSC:
a proposed IPC revision;
revised IPP-A, if appropriate;
revised Individual Program Plans (IPPs); and
documentation to HHSC within seven calendar days of notification by the DSA.
For the above, the CMA must use the date which the DSA RN documented determination the individual was subject to immediate jeopardy without the provision of additional CFC PAS/HAB, respite, nursing, dental services, or an adaptive aid that is not included on the individual's IPC as the IPC revision effective date.
The documentation furnished to the CMA by the DSA must include:
HHSC authorizes the IPC only if, after reviewing the documentation, HHSC determines the service was necessary to prevent the individual's health and safety from being placed in immediate jeopardy.
At HHSC request, the CMA must submit additional documentation supporting the proposed IPC revision to HHSC within 10 calendar days.
2340 Transfer
When the individual/legally authorized representative (LAR) notifies the case manager they wish to be transferred to a different agency(s), the case manager must:
document in the individual's IPP-A the date the transfer request was received;
provide the individual/LAR with the most current choice list document for the applicable catchment area;
within three business days, make transfer arrangements with the individual/LAR, the receiving CMA DSA or FMSA, as appropriate;
establish an effective date for the individual's transfer that is at least 14 calendar days after the date of receiving notice of intent to transfer; and
coordinate with the agencies involved in the transfer to determine the number of needed service units for each authorized service code.
The current CMA must submit the following to HHSC before the effective date of the transfer:
the individual's currently authorized IPC
The following forms may need to be completed as part of the transfer process:
The following submission standards apply when submitting transfer paperwork to HHS:
2350 IPP Service Review
The case manager is responsible for ongoing monitoring of:
the provision of CLASS program and CFC services; and
the status of non-CLASS program services and supports.
The case manager must meet with the individual or LAR in the individual's home, or other location if services are not primarily provided in the individual’s home, to review the IPC and update the IPP-A if needed. CMA Individual Program Plan (IPP) service reviews will occur in accordance with the schedule in Appendix X, IPP Service Summary/IPP Service Review Due Dates Chart, from the effective date of the most recent enrollment or renewal IPC. The fourth IPP service review of the IPC year is combined with the meeting of the SPT to develop a renewal IPC. The IPP-A and SPT notes will document the development of the renewal IPC using person-centered planning processes. The case manager must use Form 3595, IPP Service Review, to document the review of the services delivered to the individual since the ninth month IPP service review.
The purpose of meeting the individual or LAR in the setting where services are delivered is to allow the case manager to verify that services listed on the IPC are delivered as described in the Individual Program Plan (IPP). This function is best accomplished by the case manager observing CLASS services in the setting in which they are provided. Since most individuals receive CLASS services in the home setting, the IPP service reviews should occur in the location where the majority of services are delivered.
While individuals or their LAR may request the case manager meet in locations other than their own home/family home, case managers should remind them that a complete assessment of services provided to the individual is required to be performed in the setting in which those services are delivered. Case managers must document when and why an individual or LAR refuses to meet in the home setting in the “General Comments” section of Form 3595.
During the IPP service review face-to-face contact with the individual, the case manager must complete Form 3595 to:
document progress or lack of progress toward goals/objectives as identified on the IPP/IPC;
assess the individual's satisfaction with the provision of CLASS program services;
determine if the service backup plan was implemented and if it met the needs of the individual; and
identify any changes to the individual's needs to include any needed revisions to the service backup plan.
The case manager is required to complete all sections of Form 3595 for CLASS services provided to an individual. The case manager may choose to print only those pages that reflect the services reviewed and provide them to the individual, the DSA and any additional CLASS service providers (FMSA, CFS, and SFS), as necessary.
If an individual's IPC includes any nursing services or CFC PAS/HAB, and any of those services are not currently identified as requiring a service backup plan, the case manager must discuss with the individual or LAR whether any of those services may now be critical to the individual's health and safety. If the case manager and individual/LAR determines either service may now be critical to the individual's health and safety, the case manager must convene the SPT to discuss development of a service backup plan.
The case manager must also ask the individual/LAR if a service backup plan was implemented during the most recent review period and discuss the implementation of the service backup plan with the individual/LAR to determine whether or not the plan was effective.
If the service backup plan was implemented and determined to be ineffective, the case manager must convene an SPT meeting to revise the service backup plan.
If a change is requested by the individual during the IPP service review, the case manager is responsible for initiating any change(s) needed and convenes the SPT, as applicable within five business days after becoming aware that the individual's needs have changed. The case manager must also update the IPP-A.
Within five business days of the IPP service review, the case manager is responsible for providing copies of the service review with the updated IPP-A to the individual, DSA and any additional CLASS service providers (FMSA, CFS, and SFS), as necessary. The case manager must maintain documentation of transmission of all necessary documents.
The following forms may need to be completed as part of the 90-day service review:
Form 3595, IPP Service Review
2400 Denial, Reduction, Suspension and Termination
An individual whose CLASS program or CFC services are denied, reduced, suspended or terminated must be given notice of adverse actions taken by HHSC and is entitled to a fair hearing.
The CMA must obtain written authorization from HHSC for all suspensions of CLASS program or CFC services.
HHSC issues a notice to the CMA of all denials of enrollment or terminations from the CLASS program. The CMA must notify the individual, DSA, FMSA, CFS and SFS provider as applicable.
Program services may be terminated if the individual does not comply with the conditions as outlined in 40 TAC §45.406 or violates any of the conditions specified in 40 TAC §45.408. Program services may also be terminated if an individual does not comply with 40 TAC §45.407, or exhibits behavior that places the health and safety of the CMA's case manager or a DSA's service provider in immediate jeopardy as described in 40 TAC §45.409.
2410 Denial
Denial is a HHSC action that disallows:
a service requested on the IPC that was not authorized on the prior IPC; or
a portion of the amount or level of the service requested on the IPC that was not authorized on the prior IPC.
Denial of a Request for Enrollment into the CLASS Program
the DSAs serving the catchment area in which the individual resides are not willing to provide CLASS program services to the individual because they have determined that they cannot ensure the individual's health and safety.
If HHSC denies a request for enrollment, HHSC sends a written notice to the individual or LAR of the denial of the individual's request for enrollment into the CLASS program and includes in the notice the individual's right to request a fair hearing in accordance with 40 TAC §45.301, Individual's Right to a Fair Hearing. HHSC sends a copy of the written notice to the individual's DSA, CMA and, if selected, FMSA.
Denial of a CLASS Program Service
HHSC denies a CLASS program service on an individual's IPC if services:
do not prevent the individual's admission to an institution;
If HHSC denies a CLASS program or CFC service on an individual's IPC, HHSC notifies the CMA in writing. Upon receipt of HHSC written notice of denial of a CLASS program or CFC service, the CMA must send Form 3624, Termination, Reduction or Denial of CLASS, to the individual/LAR of the denial of the service, copying the individual's DSA and, if selected, FMSA, CFS or SFS provider.
The following forms may need to be completed as part of a suspension denial of services:
The following submission standards apply when submitting a request for an appeal to HHSC:
Written documentation established by the CMA in the event of a verbal request for appeal by individual/LAR (only if individual/LAR did not exercise their appeal rights using Form 3624)
Form 4800-DA, 4800-D Addendum (only if there are more than three other hearing participants who require notification of a hearing)
2420 Reduction
Reduction is an HHSC action taken because of a review of an IPC that decreases the amount or level of a service authorized by HHSC on an IPC.
HHSC will perform utilization review on all IPCs that meet criteria outlined in Section 5000, Utilization Review (UR). All services and units of service included on a proposed IPC must be justified by the SPT.
HHSC CLASS Program staff review the IPC to ensure the services on the IPC:
are the most appropriate type and amount of services to meet the individual's needs; and
The case manager has the responsibility to gather the following information for the HHSC CLASS program staff:
professional observations; or
The case manager must summarize this information using the appropriate IPP.
As necessary during the review of a proposed IPC, HHSC CLASS program staff will ask case managers to provide additional justification if the initial information submitted with a proposed IPC is not sufficient to demonstrate the need for requested services or does not meet requirements for a CLASS IPC as outlined in Section 1000, Introduction. If information submitted to HHSC by the case manager does not provide sufficient information to justify requested units of services, HHSC will modify the IPC by reducing the number of units of services as necessary and will send the CMA a copy of the modified IPC.
If an individual's services are reduced, the CMA must notify the individual and provide a copy of the notification to the DSA, FMSA and Support Family Services provider, as applicable, of the documentation of the reason for the reduction. Upon receipt of a written notice proposing to reduce a service, the CMA must inform the individual or LAR of the HHSC decision. The CMA informs the individual of the right to request a fair hearing.
The case manager sends written notice on Form 3624, Termination, Reduction or Denial of CLASS, to the individual allowing 12 days for the participant individual to respond before taking any action to reduce services.
If the individual or LAR requests a fair hearing before the effective date of the reduction of a CLASS program service, as specified in the written notice, the DSA must provide the service to the individual in the amount authorized in the prior IPC while the appeal is pending.
The following forms may need to be completed as part of a suspension reduction of services:
2430 Suspension
Revision 17- 1; Effective November 1, 2017
Individuals may not receive CLASS program or CFC services during a period of time in which they are admitted to a facility listed in this section. Individuals must be suspended without prior notification from CLASS program or CFC services until such time as the individual returns to his own or family home or is terminated from the CLASS program. The individual is not eligible for continuation of CLASS program or CFC services until the fair hearing process is completed because suspension of an individual's services is effective the date the individual was temporarily admitted to one of the facilities listed below, or leaves the state and, therefore, the individual is not given advance notice of the suspension.
Within two business days after the CMA becomes aware of a situation that necessitates an individual's CLASS program or CFC services to be suspended, the CMA must send a written request for suspension with written supporting documentation to HHSC CLASS program staff.
HHSC notifies the individual's CMA in writing of whether it authorizes a suspension of CLASS program or CFC services. Suspension is a HHSC action taken:
upon an individual's admission for any length of time up to 180 consecutive calendar days to one of the following facilities:
a residential facility operated by the Texas Youth Commission, a jail or prison; or
upon an individual leaving the state for up to 180 consecutive calendar days, except when an individual is receiving certain services available through the CDS option while the individual is temporarily staying at a location outside the state of Texas. For more details, see Information Letter No. 16-35, Receiving Services Outside the State of Texas in the CLASS and DBMD Programs.
Upon receipt of a written notice from HHSC authorizing the suspension of CLASS program or CFC services, the CMA must send the written notice of suspension to the individual/ LAR, DSA and FMSA, if applicable. The written notice includes the individual's right to request a fair hearing. The period of suspension is the length of the admission to the facility or the time spent in another state. An individual may remain on suspension from CLASS program or CFC services for up to 180 calendar days. HHSC may extend an individual's suspension for 30 calendar days upon the CMA's request.
2440 Termination
Revision 17-1; Effective November 1 , 2017
Termination is a HHSC action that results in the loss of the individual's authorized services in the CLASS program and CFC.
2441 Termination With Advanced Notice
an ICF/IID licensed or subject to being licensed in accordance with Texas Health and Safety Code, Chapter 252 or certified by HHSC, unless the individual is receiving out-of-home respite in the facility;
a residential child-care operation licensed or subject to being licensed by DFPS , unless it is a foster family home or a foster group home;
a facility licensed or subject to being licensed by DSHS ;
a residential facility operated by the Texas Juvenile Justice Department, a jail or prison; or
DSAs serving the catchment area in which the individual resides are not willing to provide CLASS program and CFC services to the individual because they have determined that they cannot ensure the individual's health and safety; or
the individual refuses to comply with a mandatory participation requirement as follows:
not completing and submitting an application for Medicaid financial eligibility to HHSC within 30 calendar days after the case manager's initial face-to-face, in-home visit. (Note: If an individual or LAR does not submit a Medicaid application to HHSC within 30 calendar days of the case manager's initial face-to-face, in-home visit as required but is making good faith efforts to complete the application, the CMA may extend this time frame in 30 calendar-day increments as approved by HHSC CLASS program staff.);
develop an enrollment IPC;
develop, renew, or revise an IPP-A;
not reviewing, agreeing to, signing and dating an IPC, IPP-A, and IPPs;
not using natural supports and other non-CLASS program or CFC services and supports for which the individual may be eligible before using CLASS program services;
not cooperating with the CMA and DSA in the delivery of CLASS program and CFC services listed on the individual's IPC, including:
working with the CMA and DSA in scheduling meetings;
attending scheduled meetings with the case manager or service provider;
being available to receive the CLASS program or CFC services;
notifying the CMA or DSA in advance if the individual or LAR is unable to attend a scheduled meeting or is unavailable to receive services in the individual's own or family home;
admitting CMA and DSA representatives to the individual's own home or family home for a scheduled meeting or to receive CLASS program and CFC services;
not cooperating with the CLASS program or CFC service providers to ensure progress toward achieving the goals and objectives described in the IPP for each CLASS program or CFC service listed on the IPC;
not paying a required copayment in a timely manner when found by HHSC to be financially eligible for CLASS program and CFC services based on the special institutional income limit;
not completing the procedures for redetermining eligibility for Medicaid, as described in the Medicaid for the Elderly and People with Disabilities Handbook;
engaging in criminal behavior in the presence of the case manager or CLASS program or CFC service provider;
permitting a person present in the individual's own or family home to engage in criminal behavior in the presence of the service provider or case manager;
acting in a manner that is threatening to the health and safety of the case manager or CLASS program or CFC service provider;
permitting a person present in the individual's own or family home to act in a manner that is threatening to the health and safety of the case manager or CLASS program or CFC service provider;
exhibiting behavior or permitting a person present in the individual's residence to exhibit behavior that places the health and safety of the case manager or CLASS program or CFC service provider in immediate jeopardy;
initiating or participating in fraudulent health care practices;
engaging in behavior that endangers the individual's health or safety; and
permitting a person present in the individual's own home or family home to engage in behavior that endangers the individual's health or safety.
If termination of services is requested based on a determination by the DSA that it cannot ensure the individual's health and safety, the CMA must include in the request specific reason(s) why the DSA determines it cannot ensure the individual's health and safety.
Prior to termination of services, an individual may choose another DSA. The CMA must provide the most current selection determination document in catchment areas with multiple DSAs. If another DSA determines the individual’s medical and nursing needs can be adequately met, the CMA must initiate a transfer IPC as described in Section 2340 of the CLASS Provider Manual.
HHSC notifies the individual's CMA in writing using Form 3624, Termination, Reduction or Denial of CLASS, or written notice from HHSC, of whether it authorizes the proposed termination of CLASS program and CFC services.
Upon receipt of HHSC notification authorizing a proposed termination of CLASS program services, the CMA must send written notice of the termination of CLASS program and CFC services to the individual or LAR within two business days. The CMA must send a copy of the termination notice to the individual's DSA and, if selected, FMSA, CFS and SFS provider. The CMA must include in the notice the individual's right to request a fair hearing.
In the event CLASS program services are terminated due to an individual's IPC cost being over $114,736.07, HHSC sends written notice to the individual or LAR of the proposal to terminate CLASS program services and includes the individual's right to request a fair hearing in the notice. HHSC sends a copy of the written notice to the individual's DSA, CMA, and if selected, FMSA.
If a CMA becomes aware an individual has not complied with a mandatory participation requirement described in this section, the CMA must immediately attempt to resolve the situation, including facilitating at least one face-to-face meeting with the SPT. If, after making attempts to resolve the situation, the CMA determines that the situation cannot be resolved, the CMA must request in writing that HHSC terminate CLASS program services for the individual. The request must be sent to HHSC within two business days of the CMA's determination the situation cannot be resolved and be supported by written documentation. The written documentation must include a description of:
the situation that resulted in the request to terminate CLASS program and CFC services; and
the attempts by the CMA and DSA to resolve the situation, including face-to-face meetings with the individual or LAR.
If an individual's CLASS Program services and CFC services are terminated, the CMA must ensure that the case manager informs the individual of alternative long-term care services and supports in the community. The explanation must include advising the individual about receiving CFC services through a managed care organization and institutional services, such as an ICF/IID. More information can be located on the Texas Health and Human Services website.
The CMA will not provide notice of a termination of CLASS program and CFC services to an individual for whom HHSC has terminated due to an IPC cost being over $114,736.07. HHSC will provide notice to individuals in this situation directly.
If the individual or LAR requests a fair hearing before the effective date of a proposed termination of CLASS program services, the DSA must provide services to the individual in the amounts authorized in the IPC while the appeal is pending.
2442 Termination Without Advanced Notice
HHSC terminates an individual's CLASS program services without advanced notice if any of the following situations exist:
the CMA or DSA receives a clearly written statement signed by the individual that the individual no longer wishes to receive CLASS program services;
an individual or a person in the individual's residence exhibits behavior that places the health and safety of the CMA's case manager or a DSA's service provider in immediate jeopardy. See Section 2443, Immediate Jeopardy of CLASS Providers.
Within two business days after the CMA becomes aware of a situation such as described above, the CMA must send a written request to terminate CLASS program and CFC services to HHSC. The written request must be accompanied by documentation supporting the request.
If an individual's CLASS Program services and CFC services are terminated, the case manager must document attempts to inform the individual of alternative long-term care services and supports in the community. The explanation must include advising the individual about receiving CFC services through a managed care organization and institutional services, such as an ICF/IID. More information can be located on the Texas Health and Human Services website at https://hhs.texas.gov/.
HHSC notifies the individual's CMA in writing of whether it authorizes the termination of CLASS program services. Upon receipt of a written notice from HHSC authorizing the termination of CLASS program services, the CMA must send written notice to the individual or LAR of the termination. The CMA must also send a hard copy of the termination notice to the individual's DSA and, if selected, FMSA, CFS and SFS provider. The CMA must include in the notice the individual's right to request a fair hearing.
2443 Immediate Jeopardy of CLASS Providers
HHSC may terminate an individual's CLASS program services if an individual or a person in the individual's residence exhibits behavior that places the health and safety of the CMA's case manager or a DSA's service provider in immediate jeopardy.
If a CMA or DSA becomes aware a situation exists that places the health and safety of the individual's case manager, CLASS program or CFC service provider in immediate jeopardy, the CMA or DSA must:
HHSC notifies the individual's CMA in writing of whether it authorizes the proposed termination of CLASS program services.
Upon receipt of written notice from HHSC authorizing the termination of CLASS program services, the CMA must, no later than the date of the termination of services, send written notice to the individual or LAR of such termination. The CMA must provide a hard copy of the termination notice to the individual's DSA and, if selected, FMSA, CFS and SFS provider. The CMA must include in the notice the individual's right to request a fair hearing.
If an individual's CLASS Program services and CFC services are terminated, the case manager must document attempts to inform the individual of alternative long-term care services and supports in the community. The explanation must include advising the individual about receiving CFC services through a managed care organization and institutional services, such as an ICF/IID. More information can be located on the HHS website.
Submission Standard — Termination
The following submission standards apply when submitting termination paperwork to HHSC:
Documentation of circumstances that support the termination of CLASS services.
Submission Standard — Appeal
Form 4800-DA, 4800-D Addendum(only if there are more than three other hearing participants who require notification of a hearing)
2500 Provision of Direct Services by CMA
A CMA or any other division of the agency must not provide any other CLASS program services to an individual receiving case management services from the CMA. This interpretation is consistent with CLASS rules in TAC, specifically 40 TAC §45.703(b)(3) that states a case manager is not employed by or contracting with a DSA to provide a direct service to an individual served by the CMA.
Title 42 of the Code of Federal Regulations (CFR) in 42 CFR §441.301(c)(1)(vi) specifies providers of home and community-based services for the individual, or those who have an interest in or are employed by a provider of home and community-based services for the individual must not provide case management or develop the person-centered service plan. After reviewing the CLASS waiver application, HHSC has determined the Centers for Medicare and Medicaid Services (CMS) intends to maintain CMA services and DSA services separate. CMS has had concerns in other Texas 1915(c) waivers regarding conflict of interest.
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