Part I.
Texas Department of Human Services
Chapter 44.
Community Care for Aged and Disabled Project CHOICE
The Texas Department of Human Services (DHS) proposes a new Chapter
44, concerning Community Care for Aged and Disabled Project CHOICE, which
consists of two client services components of a grant received by the Texas
Health and Human Services Commission for Project CHOICE (Consumers Have Options
for Independence in Community Environments) from the federal Health Care Financing
Administration. DHS proposes new §44.1, concerning Definitions; §44.101,
concerning Transition to Life in the Community Client Eligibility Criteria;
§44.102, concerning Application for Transition to Life in the Community
Benefits; §44.103, concerning Transition to Life in the Community Program
Benefits; §44.104, concerning Transition to Life in the Community Client
Rights; §44.201, concerning Client Eligibility Criteria for Project CHOICE
Presumptive Eligibility Services; §44.202, concerning Period of Presumptive
Eligibility; §44.203, concerning Presumptive Eligibility Program Benefits;
§44.204, concerning Authorization of Presumptive Eligibility Services;
§44.205, concerning Initiation of Presumptive Eligibility Services; §44.206,
concerning Provider Billing for Presumptive Eligibility Services; and §44.207,
concerning Provider Refusal to Deliver Presumptive Eligibility Services. The
purpose of the new chapter is to allow DHS to implement two pilot programs:
Transition to Life in the Community (TLC) program which will provide transition
grants to individuals in nursing facilities who have been accepted in certain
community-based programs, for the costs associated with moving and reestablishing
community residences; and presumptive eligibility services which will provide
for the initiation of time-limited services through certain community-based
programs to applicants who appear to meet the financial and other eligibility
criteria pending further verifications.
Eric M. Bost, commissioner, has determined that for the first five-year
period the proposed sections will be in effect there will be no fiscal implications
for state or local governments as a result of enforcing or administering the
sections.
Mr. Bost also has determined that for each year of the first five years
the sections are in effect the public benefit anticipated as a result of enforcing
the sections in the pilot site areas will be that additional resources will
be available to help individuals in institutional settings to move to community
settings, and that some community-based services may be initiated more quickly
to individuals who appear to meet all eligibility criteria by deferring verifications.
The Transition to Life in the Community rules will not have any adverse
effects on small businesses because the transition funds will go directly
to the individual. The rules for the presumptive eligibility services will
guarantee payment to the contracted providers for services which were authorized
for individuals who are later determined to be ineligible for ongoing services
but will result in a delay in payment until the final eligibility decision.
Overall, no adverse economic effects are expected on businesses of any size
because of the limited numbers of recipients expected to be able to be served
through the grant funds available.
Questions about the content of this proposal may be directed to Randy Wyatt
at (512) 438-4807 in DHS's client eligibility section. Written comments on
the proposal may be submitted to Supervisor, Rules and Handbooks Unit-143,
Texas Department of Human Services E-205, P.O. Box 149030, Austin, Texas,
78714-9030, within 30 days of publication in the
Texas Register
.
Subchapter A. Definitions
40 TAC §44.1
The new section is proposed under the Human Resources Code,
Title 2, Chapters 22 and 32, which authorizes the department to administer
public assistance programs and under Texas Government Code §531.021,
which provides the Health and Human Services Commission with the authority
to administer federal medical assistance funds.
The new section implements the Human Resources Code, §§22.001-22.030
and §§32.001-32.042.
§44.1.Definitions.
The following words and terms, when used in this chapter, shall have
the following meanings, unless the content clearly indicates otherwise.
(1)
Case manager--An employee of the Texas Department of Human
Services (DHS), or of an agency which has contracted with DHS to provide case
management services, who provides case management services. The case manager
determines eligibility and benefit levels in the Transition to Life in the
Community (TLC) Program, subject to final approval by DHS. The case manager
also determines an applicant's eligibility for program services, including
presumptive eligibility for limited program services.
(2)
CBA--The Community Based Alternatives program, a Medicaid
waiver program, based on the Social Security Act, §1915(c), which provides
a comprehensive array of community-based services for adults age 21 and older
who meet the medical necessity criteria for nursing facility care and who
meet all other eligibility criteria for this waiver.
(3)
CLASS--The Community Living Assistance and Support
Services program, a Medicaid waiver program, based on the Social Security
Act, §1915(c), which provides a comprehensive array of community-based
services for certain individuals who qualify for an intermediate care facility
for the mentally retarded (ICF-MR) VIII level of care and who meet all other
eligibility criteria for this waiver. This program operates in designated
specific counties in Texas.
(4)
Community setting--For persons seeking services through
the CLASS or CBA waiver programs, a community setting is any living arrangement
chosen by the individual which allows him to receive waiver services from
the particular waiver program. A community setting is any long-term living
arrangement other than a nursing facility, state hospital, state school, medical,
rehabilitation or psychiatric hospital, school for the deaf or blind, Texas
Youth Commission facility, Texas Department of Criminal Justice facility,
ICF-MR facility, an unlicensed facility, or a licensed personal care facility
or adult foster care home which does not contract with DHS to deliver services
through the CBA program.
(5)
DHS--The Texas Department of Human Services.
(6)
Institutional setting--A long-term care nursing facility
or ICF-MR Level VIII facility licensed by the Texas Department of Human Services.
(7)
Presumptive eligibility--A tentative time-limited
approval for an individual to receive limited services through the CBA or
CLASS waiver programs or the 1929(b) program pending verification and final
determination of eligibility.
(8)
Project CHOICE--A grant-funded project (Consumers
Have Options for Independence in Community Environments) which provides services
in a limited geographic area to individuals who are elderly and persons with
disabilities who either reside in institutional settings or who are at immediate
risk of institutional placement. Services to eligible individuals will be
provided through the TLC program and/or time-limited presumptive eligibility
for limited services through the CBA, CLASS, or 1929(b) programs.
(9)
TLC--The Transition to Life in the Community program,
a component of the Project CHOICE grant program, which provides a one-time
financial grant to individuals to help them move from Medicaid-funded placement
of at least six months duration in an institutional setting into a community
setting.
(10)
1929(b) program--A Community Care to Aged and Disabled
program authorized under §1929(b) of the Social Security Act which provides
non-technical, medically-related personal care services prescribed by a physician
for eligible clients whose health problems cause them to be functionally limited
in performing activities of daily living.
This agency hereby certifies that the proposal has been
reviewed by legal counsel and found to be within the agency's legal authority
to adopt.
Filed with the Office of the Secretary of State, on
April 9, 1999.
TRD-9902099
Paul Leche
General Counsel, Legal Services
Texas Department of Human Services
Earliest possible date of adoption: May 23, 1999
For further information, please call: (512) 438-3765
40 TAC §§44.101-44.104
The new sections are proposed under the Human Resources Code,
Title 2, Chapters 22 and 32, which authorizes the department to administer
public assistance programs and under Texas Government Code §531.021,
which provides the Health and Human Services Commission with the authority
to administer federal medical assistance funds.
The new sections implement the Human Resources Code, §§22.001-22.030
and §§32.001-32.042.
§44.101.Transition to Life in the Community Client Eligibility Criteria.
To be eligible to receive benefits from the Transition to Life in
the Community (TLC) program, the individual must meet the criteria specified
in paragraphs (1) and (2) of this section.
(1)
The individual must meet one of the criteria listed in
subparagraphs (A)-(C) of this paragraph:
(A)
be accepted for services under the Community Based Alternatives
(CBA) program and require the benefits of TLC services in order to move to
a setting which is acceptable to the CBA program;
(B)
be accepted for services under the Community Living Assistance
and Support Services (CLASS) program and require the benefits of TLC services
in order to move to a setting which is acceptable to the CLASS program; or
(C)
be accepted for services under the Medically Dependent
Children Program (MDCP) and require the benefits of TLC services in order
to move to a setting which is acceptable to the MDCP program;
(2)
The individual must meet all of the criteria
specified in subparagraphs (A)-(E) of this paragraph:
(A)
not have received prior benefits through the TLC program;
(B)
be a Texas Medicaid recipient who resided in a licensed
nursing facility or intermediate care facility for the mentally retarded for
at least six months;
(C)
demonstrate a financial ability to maintain ongoing household
expenses after the temporary TLC assistance has been exhausted;
(D)
move to a community setting within 60 days of the date
eligibility for TLC is determined, otherwise, the application will be denied;
and
(E)
agree in writing to provide to the Texas Department of
Human Services (DHS) receipts for all goods, services, or supplies purchased
with program funds and to make restitution to DHS for funds which were not
spent and/or were spent for goods, services, or supplies that were not approved
by DHS.
§44.102.Application for Transition to Life in the Community Benefits.
(a)
An applicant or his authorized representative must complete
and sign an application for the Transition to Life in the Community (TLC)
benefits to begin the eligibility determination process for the TLC program.
(b)
Applications are processed on a first-come, first-served
basis according to the date on which the state office of the Texas Department
of Human Services is notified that the service plan for Community Living Assistance
and Support Services, Community Based Alternatives, or Medically Dependent
Children Program services has been developed and that the individual has applied
TLC benefits.
§44.103.Transition to Life in the Community Program Benefits.
(a)
Transition to Life in the Community (TLC) program benefits
are contingent upon the availability to the Texas Department of Human Services
(DHS) of special or temporary funds for this program.
(b)
Program benefits are available only to individuals residing
in a nursing facility or intermediate care facility for the mentally retarded
(ICF-MR) who are leaving the facility and entering the Community Living and
Support Services (CLASS), Community Based Alternatives (CBA), or Medically
Dependent Children Program (MDCP) waiver programs in a living arrangement
allowable in the specific waiver program.
(c)
Availability of funds and approval of benefits must be
confirmed by DHS before commitment is made to disburse funds.
(d)
An individual may receive program benefits only once.
(e)
The TLC program will not provide benefits which the individual
is eligible and able to receive through any other program.
(f)
The TLC program benefits may not include items or services
which are included in the reimbursement rate for CBA, CLASS, or MDCP contracted
providers.
(g)
An eligible individual may receive a one-time grant of
up to $2,500 to pay for the following expenses related to moving and household
start-up costs, if the expenses are approved by the case manager and DHS:
(1)
expenses directly related to moving, such as the cost of
paying others to move household belongings, the cost of moving cartons, and
the cost of transporting the individual to the community setting;
(2)
rent deposits, limited to the first and last month's
rent plus reasonable damage and security deposits;
(3)
utility deposits, including deposits required by electricity,
gas, water, waste water, telephone, and sanitation companies;
(4)
cooking utensils, dishes, cleaning supplies, furniture,
appliances, towels, sheets, blankets, and other items needed to set up a household;
or
(5)
other moving-related expenses and household start-up
costs approved by the case manager and DHS.
(h)
If individuals accepted into the CLASS, CBA, or MDCP programs
will share a common household, the information in paragraphs (1)-(2) of this
subsection apply:
(1)
If all individuals meet the eligibility criteria, each
individual may receive a grant up to the maximum as long as no duplication
of expenses occurs.
(2)
If only one household member meets the eligibility
criteria, only the eligible household member may receive the grant. The ineligible
household member's moving-related expenses and household start-up costs may
be included in the eligible household member's grant, subject to the $2,500
limit, provided the ineligible household member is moving to the same community
setting as the eligible household member.
(i)
Payments may be made directly to the eligible individual,
or his authorized representative. The payee must obtain a vendor identification
number from the Texas State Comptroller of Public Accounts before payment
can be made.
§44.104.Transition to Life in the Community Client Rights.
(a)
The individual requesting Transition to Life in the Community
(TLC) funds and/or the authorized representative will receive written notification
of the eligibility decision for TLC from the case manager. If the individual
is determined eligible, the written notice states the amount of the grant
the individual will receive.
(b)
The individual requesting TLC funds and/or the authorized
representative may also request a hearing to appeal the denial of eligibility
or the level of benefits if the request is made within 90 days of the date
of notification of the eligibility decision.
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal authority to adopt.
Filed with the Office of the Secretary of State, on
April 9, 1999.
TRD-9902100
Paul Leche
General Counsel, Legal Services
Texas Department of Human Services
Earliest possible date of adoption: May 23, 1999
For further information, please call: (512) 438-3765
40 TAC §§44.201-44.207
The new sections are proposed under the Human Resources Code,
Title 2, Chapters 22 and 32, which authorizes the department to administer
public assistance programs and under Texas Government Code §531.021,
which provides the Health and Human Services Commission with the authority
to administer federal medical assistance funds.
The new sections implement the Human Resources Code, §§22.001-22.030
and §§32.001-32.042.
§44.201. Client Eligibility Criteria for Project CHOICE Presumptive Eligibility Services.
To be eligible through the Project CHOICE (Consumers Have Options for
Independence in Community Environments) program for presumptive eligibility
benefits of limited program services through the Community Based Alternatives
(CBA), Community Living and Support Services (CLASS), or 1929(b) programs,
an individual must meet the all of the criteria specified in paragraphs (1)-(11)
of this section:
(1)
not be currently certified in a Medicaid program which
makes the individual financially eligible for the program from which he is
requesting services;
(2)
submit a completed, signed, and dated application
for Medicaid financial eligibility;
(3)
be appropriate to consider for services with regard
to waiting lists for the program services requested and the availability of
program funds; specifically, to bypass the CBA program interest list, an individual
must be eligible for presumptive eligibility services, and be able to be served
within available Project CHOICE funds;
(4)
participate in and cooperate with the Texas Department
of Human Services (DHS) staff or contractors in the face-to-face interview
and assessment process, including the provision of financial and medical information
necessary to make a presumptive eligibility decision;
(5)
not have reported income or resources in excess of
the thresholds established by DHS;
(6)
not have circumstances requiring evaluation of trust(s),
annuities, spousal impoverishment or protected resource amount(s);
(7)
appear to meet the medical necessity/level of care
criteria required by the program for which he is applying;
(8)
be determined by case management staff authorized
to make presumptive eligibility decisions to be likely to meet all eligibility
criteria for the program through which the individual will receive services
pending final verification and determination of eligibility;
(9)
sign a presumptive eligibility service agreement;
(10)
be at risk of institutional placement; and
(11)
reside in a Project CHOICE pilot county.
§44.202. Period of Presumptive Eligibility.
The period of presumptive eligibility continues until the final decision
regarding eligibility is reached, but in no case will presumptive eligibility
services be authorized for more than 90 days, except in the situations of
short-term continuation of services to ineligible individuals. Individuals
receiving program services through presumptive eligibility who are determined
ineligible for ongoing program benefits may continue to receive the presumptive
eligibility services for 30 days after the ineligibility decision. Presumptive
eligibility services will not be continued beyond the 30-day continuation
of benefits period even if the decision of ineligibility is appealed.
§44.203. Presumptive Eligibility Program Benefits.
(a)
Presumptive eligibility program benefits are contingent
upon the availability to the Texas Department of Human Services (DHS) of special
or temporary funds for this program.
(b)
Services available through a presumptive eligibility determination
are limited to:
(1)
personal assistance services, nursing services, and medical
supplies (not including prescription drugs) for the Community Living and Support
Services waiver program;
(2)
personal assistance services, nursing services, medical
supplies (not including prescription drugs), adult foster care, and assisted
living/residential care services for the Community Based Alternatives program;
and
(3)
personal assistance services in the 1929(b) program.
(c)
Individuals receiving presumptive eligibility services
are not eligible to receive Medicaid benefits until and unless a final determination
of eligibility for ongoing program services is made. Individuals receiving
presumptive eligibility services will not receive a Medicaid eligibility notification
letter.
§44.204. Authorization of Presumptive Eligibility Services.
Texas Department of Human Services staff will authorize contracted
program service providers to deliver the limited services identified in §44.203
of this title (relating to Presumptive Eligibility Program Benefits) to individuals
determined to be eligible.
§44.205. Initiation of Presumptive Eligibility Services.
(a)
Contracted program service providers are expected to expedite
the initiation of presumptive eligibility services and must initiate services
no later than the day after presumptive eligibility services are authorized.
(b)
Verbal physician's orders must be obtained and documented
if required for initiation of presumptive eligibility services.
§44.206. Provider Billing for Presumptive Eligibility Services.
(a)
The authorized provider will be notified of the final
eligibility decision. Any modifications to the authorization or service plan
for ongoing services will be completed by the case manager as necessary.
(b)
For individuals determined eligible for ongoing program
benefits, the contracted provider must submit the billing for services delivered
during the presumptive eligibility period through normal billing procedures.
(c)
For individuals determined ineligible for ongoing program
benefits, the contracted provider must submit the billing for services delivered
during the presumptive eligibility period to the state office.
§44.207. Provider Refusal to Deliver Presumptive Eligibility Services.
Contracted providers are required to deliver the limited presumptive
eligibility services authorized by the Texas Department of Human Services
staff or contract case management staff. Refusal to deliver authorized services
will be considered to be a violation of program requirements.
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal authority to adopt.
Filed with the Office of the Secretary of State, on
April 9, 1999.
TRD-9902101
Paul Leche
General Counsel, Legal Services
Texas Department of Human Services
Earliest possible date of adoption: May 23, 1999
For further information, please call: (512) 438-3765
Subchapter L. Fair Hearings
Subchapter B. Transition to Life in the Community Program
Subchapter C. Presumptive Eligibility Through the Project CHOICE Program
Chapter 79.
Legal Services