Hcbs waiver program texas

CMS requires all states to submit a transition plan describing their planned initiatives and activities to achieve compliance with the federal HCBS settings regulations. Heightened scrutiny is a review process required by CMS for settings that are presumed to have institutional or isolating qualities. The purpose of heightened scrutiny is to determine:.

More information about the heightened scrutiny process is available at this link. Texas Health and Human Services. Search the Texas HHS site. See Section Classification Levels, for additional information. Specialized nursing services may be used when a member requires, as determined by a physician, daily skilled nursing to:.

Therapy services include the full range of activities under the direction of a licensed therapist within the scope of her or his state licensure. Therapy services are provided directly by licensed therapists or by assistants under the supervision of licensed therapists in the member's home, or the member may receive the therapy in an outpatient center or clinic.

If the therapy is provided outside the member's residence based on the member's choice, the member is responsible for providing her or his own transportation or accessing the Medicaid Medical Transportation Program MTP. If the therapy is provided outside the member's residence because of the convenience of the provider, the provider is responsible for providing the member's transportation. Individuals providing therapy services must be licensed in Texas in their profession or be licensed or certified as assistants and employed directly or through sub-contract or personal service agreements with a provider or through the Consumer Directed Services CDS Option.

PT is defined as specialized techniques for evaluation and treatment related to functions of the neuro-musculo-skeletal systems provided by a licensed physical therapist or a licensed PT assistant directly supervised by a licensed physical therapist. PT is the evaluation, examination and utilization of exercises, rehabilitative procedures, massage, manipulations and physical agents such as mechanical devices, heat, cold, air, light, water, electricity and sound in the aid of diagnosis or treatment.

OT consists of interventions and procedures to promote or enhance safety and performance in activities of daily living ADLs , instrumental activities of daily living IADLs , education, work, play, leisure and social participation.

It is provided by a licensed occupational therapist or a certified OT assistant directly supervised by a licensed occupational therapist. It is provided by a speech-language pathologist or a licensed associate in speech-language pathology under the direction of a licensed speech-language pathologist. Upon member request or recommendation from the nurse, primary care provider or service coordinator for a therapy assessment, the managed care organization MCO service coordinator must work with the member to select a provider for the assessment.

The assessment must be submitted by the provider for the MCO to authorize service hours based on physician orders and medical necessity MN review. Any therapy for the management of a chronic condition must be included on the individual service plan ISP.

Cognitive rehabilitation therapy is provided when determined to be medically necessary MN through an assessment conducted by an appropriate professional. Cognitive rehabilitation therapy is provided in accordance with the individual service plan ISP developed by the assessor, and includes reinforcing, strengthening or re-establishing previously learned patterns of behavior, or establishing new patterns of cognitive activity or compensatory mechanisms for impaired neurological systems.

Qualified providers include:. Adaptive aids and medical supplies are specialized medical equipment and supplies, including devices, controls or appliances that enable members to increase their abilities to perform activities of daily living ADLs , or to perceive, control or communicate with the environment in which they live. This service also includes items necessary for life support, ancillary supplies and equipment necessary to the proper functioning of such items; and durable and non-durable medical equipment not available under the Texas state plan, such as vehicle modifications, service animals and supplies, environmental adaptations, aids for daily living, reachers, adapted utensils and certain types of lifts.

Adaptive aids, including repair and maintenance to include batteries not covered by the warranty, consist of but are not limited to following:. The owner must sign and date the approval. The MCO must maintain documentation that the contracted provider ensured the specifications for a vehicle modification included information on the vehicle to be modified, including:.

Necessary items related to hospital beds could include electric controls, manual cranks or other items related to the use of the bed. Specialty sheets, such as hospital bed sheets, may be covered. Examples of active infectious diseases that qualify are Methicillin-resistant Staphylococcus aureus MRSA and hepatitis.

Gloves may be purchased for family or caregiver use to provide wound care to protect the member. Documentation by the MCO-contracted provider must support the need of gloves to be left at the residence and for family or caregiver use only. If the member has other conditions requiring frequent use of gloves, the MCO nurse must give his or her approval.

These items include, but are not limited to:. The MCO must provide documentation supporting the medical need for all adaptive aids and medical supplies. The documentation must be provided by the member's ordering, referring or prescribing provider. This can be a physician, physician assistant, nurse practitioner, registered nurse RN , physical therapist, occupational therapist or speech pathologist.

The service coordinator must use Form H, Individual Service Plan — Addendum, to document medical need and the rationale for purchasing the item s. The MCO determines if the documentation submitted is adequate, and makes the decision as to whether an adaptive aid or medical supply is needed and related to the member's condition.

The MCO makes the final decision if the purchase is necessary and will be authorized on the individual service plan ISP. If the member's request for a particular adaptive aid or medical supply is denied, the member must receive written notice of action of the denial of the specific item following the requirements outlined in the Uniform Managed Care Manual , Chapter 3. If the member requests an item the MCO deems is not medically necessary or related to the member's disability or medical condition, the MCO must send a notice of action to the member.

For situations in which the member requests an adaptive aid or medical supply, and the item s are documented by the nurse or other medical professional to be medically necessary, the MCO has the option of approving the item s.

If not approved, the MCO must send a notice of action to the member. The member may appeal the denial by filing an appeal with the MCO. The member does not receive the adaptive aid or medical supply unless the denial is reversed. If the denial is reversed, the item is added to the ISP. The cost of the item is reflected in the ISP in effect at the time of the appeal. Service plans should be individualized to the member. All items must be related to the member's disability or medical condition and used to support or increase level of independence.

If the provider cannot deliver the adaptive aids by the appropriate time frames, the provider must notify the MCO via Form HMC , Managed Care Programs Communication, and include the reasons the adaptive aid will be late. The MCO reviews the information to determine if the reason given for the delay is adequate or if additional intervention is necessary. It may be necessary for the MCO to discuss the reasons for the delayed delivery with the member and provider staff.

If the authorization on the new ISP causes the ISP to exceed the annual cost limit, the nurse may authorize the service using the date the item was ordered by the provider as the date of service delivery and the provider may bill against the previous ISP.

Use the following procedures if attempting to purchase the lift chair using Medicare funding. Once the managed care organization MCO determines a lift chair may be needed or is requested by the member, the MCO assesses the member to determine if the member meets all of the following criteria required for Medicare to pay for the lift mechanism:.

The MCO approves the cost of the lift chair plus the mechanism if the request meets all criteria and the above documentation is received. To avoid billing issues, the effective date of the change to add the funds for the lift mechanism must be the same as the effective date of the first change completed to approve the lift chair minus the mechanism.

If a member changes to another managed care organization MCO while an adaptive aid is on order or in the process of being delivered, the MCO which authorized the service is responsible for payment and delivery of the adaptive aid. Rental of equipment allows for repair, purchase or replacement of the equipment, or temporary usage of the equipment. The length of time for rental of equipment must be based on the individual circumstances of the member.

The cost of renting equipment versus purchasing equipment may be explored, if you are currently renting the equipment. Rentals can be more cost-effective than direct purchase of an item. The expected duration of the use of equipment may be considered in the decision to rent or purchase.

It may be more cost-effective, after renting for a period of time, to purchase the equipment instead of continuing to rent. The managed care organization MCO must purchase and ensure delivery of any adaptive aid within 14 business days of being authorized except for vehicle modifications to purchase the adaptive aid, counting from either the effective date of the individual service plan ISP form or the date the form is received, whichever is later.

If delivery is not possible in 14 business days , the MCO must document the reason for the delay. The MCO must notify the member and document notification of any delay, with a new proposed date for delivery. The notification must be provided on or before the 14th business da y following authorization. If the delivery does not occur by the new proposed date, the MCO must document any further delays, as well as document member notification, until the adaptive aids are delivered. The MCO must work with the provider and member to ensure the vehicle modification takes place as expeditiously as possible.

The provider must deliver medical supplies within five business days from the start date on the individual service plan ISP. For example, if the member has a supply of diapers that is expected to last for one month, the diapers authorized on the ISP do not need to be delivered immediately.

If the provider cannot ensure delivery of a medical supply within five business days due to unusual or special supply needs or availability, the provider must submit Form HMC , Managed Care Programs Communication, to the managed care organization MCO before the fifth day explaining why the medical supply cannot be delivered within the required time frame and including a new proposed date for the delivery.

If there is an existing supply of medical supplies on the service initiation date, the MCO must write "existing supply of needed medical supplies on hand" in the progress notes as verification that supplies were available to the member and did not require delivery at this time. HHSC invites members of the public, including people receiving HCBS and their families, providers and other stakeholders to submit comments on the list of settings identified for heightened scrutiny review.

The public comment period will end October 24, The list of settings and instructions for submitting public comments can be found in the Heightened Scrutiny PDF.

CMS has given states until March 17, to bring Medicaid programs into compliance with the regulations. The purpose of the regulations is to ensure people receive Medicaid HCBS in settings that are integrated in the community. Medicaid HCBS settings must also be integrated in and support full access to the greater community, including opportunities to:.

CMS requires states to submit a transition plan describing their planned initiatives and activities to achieve compliance with the federal HCBS settings regulations.

The transition plan must include:. The initial plan and amended versions are available at the following links:.

These settings must go through a heightened scrutiny review by CMS. CMS requires states to identify settings that meet the criteria above and submit to CMS a list of settings that the state believes can overcome the institutional or isolating presumption.