25 TAC §§621.121-621.128
The new sections are proposed under Chapter 73 of the Human
Resources Code, which provides the agency with the authority to administer
public programs for developmentally delayed children, and under §531.021(a),
Government Code, which provides the Health and Human Services Commission with
the authority to administer federal medical assistance funds.
No other statutes, articles or codes are affected by the proposed new sections.
§621.121.Introduction.
Case Management Services for Infants and Toddlers with Developmental
Disabilities are included in the Texas Medical Assistance Program (Medicaid).
The general operation of the Texas Early Childhood Intervention (ECI) program
is governed by the Texas Interagency Council on Early Childhood Intervention
Services.
§621.122.Definitions.
The following words and terms, when used in this subchapter, shall
have the following meanings, unless the context clearly indicates otherwise:
(1)
Assessment--The ongoing procedures used by appropriate
qualified personnel throughout the period of a child's eligibility to identify:
(A)
the child's unique needs and strengths;
(B)
the family's strengths and needs related to their child's
development; and
(C)
the nature and extent of intervention services needed by
the child and the family in order to assess subparagraphs (A) and (B) of this
paragraph.
(2)
Board--The entity designated as the lead agency
by the Governor under Public Law 102-119. The Board has the final authority
and responsibility for the administration, supervision, and monitoring of
programs and activities under this system. The Board has the final authority
for the obligation and expenditure of funds and compliance with all applicable
laws and rules.
(3)
Caregiver--A person, such as a parent, foster parent,
grandparent, child-care worker, who has responsibilities for the care of a
child.
(4)
Case management--Services provided to assist eligible
individuals in gaining access to needed medical, social, educational, developmental,
and other appropriate services.
(5)
Case manager (service coordinator)--An Early Childhood
Intervention (ECI) program staff person who is assigned to a child and/or
family, who is the single contact point for families, and who is responsible
for assisting and empowering families in accessing services and coordinating
those services.
(6)
Developmental delay--A significant variation in normal
development in one or more of the following areas as measured and determined
by appropriate diagnostic instruments and procedures by an interdisciplinary
team and by informed clinical opinion: cognitive development; physical development,
including vision and hearing, gross and fine motor skills, and nutrition status;
communication development; social and emotional development; and adaptive
development or self-help skills.
(7)
Developmental disability--Children from birth to age
three who have substantial developmental delay or specific congenital or acquired
conditions with a high probability of resulting in developmental disabilities
if services are not provided.
(8)
ECI--The Texas Early Childhood Intervention Program.
(9)
Early Childhood Intervention (ECI) services--Individualized
intervention services provided to children from birth to age three, and their
families, as:
(A)
determined by the interdisciplinary assessment and listed
in the individualized family services plan; and
(B)
provided in accordance with the rules of the Texas Interagency
Council on Early Childhood Intervention Services in Chapter 621 of this title
(relating to Early Childhood Intervention).
(10)
Individualized family services plan (IFSP)--A
written plan, developed by the interdisciplinary team, based on all assessment
and evaluation information and including the family's description of their
strengths and needs, which outlines the intervention services for the child
and the child's family.
(11)
Interdisciplinary team--The child's parent(s) and
a minimum of two professionals from different disciplines who meet to share
evaluation information, determine eligibility, assess needs, and develop the
individualized family service plan (IFSP). The team must include the case
manager (service coordinator) who has been working with the family since the
initial referral, or the person responsible for implementing the IFSP, and
a person directly involved in conducting the evaluations and assessments.
(12)
Intake--Process that begins with telephone or face-to-face
contacts with the child's family to provide information about early intervention
and case management and to assist the child and family in gaining access to
the evaluation and the assessment process. This process establishes potential
eligibility for ECI services, provides a basic introduction to the program's
philosophy and operating procedures, gathers information needed for enrollment,
and schedules and helps the family prepare for a comprehensive interdisciplinary
evaluation and assessment. Pre-Plan of Care service coordination is provided
as needed.
(13)
Monitoring--Periodic tracking, observation and follow
up to ensure that services have been delivered, that services have been delivered
on a timely basis, and that the services are addressing the clients' needs.
Monitoring and follow up activities are conducted as needed and are documented
in the child's case folder.
(14)
Needs assessment--The needs assessment is conducted
and documented by the case manager in conjunction with the Medicaid client's
family. The documentation lists medical, social, nutritional, educational,
developmental, and other appropriate needs of the Medicaid client. Individuals
found not to be eligible for early intervention services, or whose families
choose not to enroll in early intervention services are to be referred to
any appropriate alternative care or services.
(15)
Plan of care--Information gathered from the comprehensive
needs assessment is incorporated into an individualized family services plan
of care (IFSP). With family consent, family concerns, priorities and resources
are identified and documented in the plan. The plan summarizes assessment
results, includes the services necessary to enhance the development of the
child and the capacity of the family to meet the child's unique needs, and
must be coordinated with other service providers involved in delivery of services
to the child and family.
(16)
Reassessment and Transition Planning--A reassessment
of the client's progress and needs is conducted at least every six months.
The case manager documents the reassessment in the client's case folder. At
reassessment the case manager will determine if modifications to the service
plan are necessary and if the level of involvement by the case manager should
be adjusted. When services are no longer needed, or the child no longer qualifies
for services, the case manager facilitates the planning, coordination, and
transition to other appropriate care.
(17)
Service coordination--Through linkage, coordination,
facilitation, assistance, anticipatory guidance, and the provision of information
about the child's medical needs to other health care providers, the case manager
ensures the recipient's access to the care, resources and services to meet
the client's needs. The case manager may assist the family in making applications
for services, confirm service delivery dates with ECI staff, providers and
supports, and assist the family with scheduling needs. The case manager assists
the family in taking responsibility for ensuring that services are performed,
and works with medical providers, ECI staff, and other community resources
to coordinate care.
(18)
Texas Health Steps--The name adopted by the State
of Texas for the federally mandated Early and Periodic Screening, Diagnosis
and Treatment (EPSDT) program. It includes the State's Comprehensive Care
Program extension to EPSDT.
(19)
Time and Financial Information (TAFI)--A combined
cost report and time study report, collected quarterly from providers.
§621.123.Reimbursable Services.
(a)
Case management services are reimbursable to Medicaid providers
who meet the conditions for provider participation as specified in §621.125
of this title (relating to Conditions for Case Management Provider Participation).
Reimbursable case management services include face-to-face and telephone contacts
with the child's caregiver on behalf of the child, or with other service providers
or professionals on behalf of the child, for the purpose of assisting that
child in gaining access to needed medical, social, educational, developmental,
and other appropriate services. Case management providers are paid one flat
monthly rate each month in which at least one reimbursable case management
contact occurred.
(b)
Case management services are not reimbursable as Medicaid
services when another payor is liable for payment or if case management services
are associated with the proper and efficient administration of the state plan.
Case management services associated with the following are not payable as
optional targeted case management services under Medicaid:
(1)
Medicaid eligibility determinations and redeterminations;
(2)
Medicaid eligibility intake processing;
(3)
Medicaid preadmission screening;
(4)
Prior authorization for Medicaid services;
(5)
Required Medicaid utilization review;
(6)
Texas Health Steps program administration;
(7)
Medicaid "lock-in" provided for under the Social Security
Act, §1915(a);
(8)
Services that are an integral or inseparable part
of another Medicaid service;
(9)
Outreach activities that are designed to locate individuals
who are potentially eligible for Medicaid; and
(10)
Any medical evaluation, examination, or treatment
billable as a distinct Medicaid-covered benefit. However, referral arrangements
and staff consultation for such services are reimbursable as case management
services.
§621.124.Recipient Eligibility for Early Childhood Intervention (ECI) Case Management Services.
In order to receive ECI services, the recipient must meet the following
criteria:
(1)
be eligible for Medicaid services during the month that
the services are provided, and
(2)
have a developmental disability, as defined in §621.122
of this title (relating to Definitions). ECI providers must determine developmental
disability based on the criteria described below:
(A)
Children are eligible who have a medically diagnosed physical
or mental condition that has a high probability of resulting in developmental
delay, including, but not limited to:
(i)
Down Syndrome and other chromosomal abnormalities;
(ii)
sensory impairments, including vision and hearing;
(iii)
inborn errors of metabolism;
(iv)
microcephaly;
(v)
failure to thrive;
(vi)
seizure disorders;
(vii)
fetal alcohol syndrome or fetal alcohol effects;
(viii)
testing positive for the Human Immunodeficiency Syndrome
(HIV) virus after 15 months of age.
(B)
Children are eligible who are delayed in one or more of
the following areas of development: cognitive, motor, communication, social-emotional,
or adaptive skills. Eligibility must be verified by the determination of the
specific level of delay by a test performance on a validated comprehensive
developmental inventory or standardized test.
(C)
A qualified professional must observe and document atypical
development during:
(i)
Administration of an assessment device, or
(ii)
Informal testing procedures in a variety of settings.
§621.125.Conditions for Case Management Provider Participation.
In order to be reimbursed for Early Childhood Intervention (ECI) services
as specified in §621.123 of this title (relating to Reimbursable Services),
a provider must:
(1)
be certified by the Texas ECI program as meeting the standards
for service providers established by the Texas Early Childhood Intervention
Program Services, as specified in this chapter;
(2)
comply with all applicable federal and state laws
and regulations governing the services provided;
(3)
ensure that services are provided by appropriately
qualified staff as specified in §621.126 of this title (relating to Qualified
Personnel);
(4)
be enrolled and approved for participation as a provider
in the Texas Medical Assistance (Medicaid) Program;
(5)
sign a written provider agreement with ECI or its
designee;
(6)
comply with the terms of the provider agreement and
all requirements of the Texas Medical Assistance Program, including regulations,
rules, handbooks, standards, and guidelines published by ECI or its designee;
and
(7)
bill for services covered by the Texas Medical Assistance
Program in the manner and format prescribed by ECI or its designee.
§621.126.Qualified Personnel.
Early Childhood Intervention (ECI) case management services must be
provided by case managers who meet the educational and work experience requirements,
commensurate with their job responsibilities, as specified in §621.24(c)(4)
of this title (relating to Recipient Eligibility for Early Childhood Intervention
(ECI) Case Management Services); Texas Early Childhood Intervention Staff
Qualification Policies (ECI Policy III.8); and who have also completed the
ECI Case Management Curriculum.
§621.127.Retention of Records.
Providers of Early Childhood Intervention (ECI) services must maintain
and retain all necessary records and claims, as specified in §621.128
of this title (relating to Provider Records), to fully document the services
and supplies provided to a Medicaid recipient. These records must be made
available promptly upon request to the Texas Early Childhood Intervention
Program (ECI), the Texas attorney general's office, ECI's designee, and representatives
of the United States Department of Health and Human Services. Upon request,
the provider must submit copies of their records, at no cost, to representatives
of the agencies specified in this section.
§621.128.Provider Records.
(a)
A provider must allow ECI and all appropriate federal and
state agencies or their representatives to inspect, monitor, or evaluate client
records, books, and supporting documents pertaining to Medicaid services provided.
The provider and the subcontractors must make these documents available at
reasonable times and for reasonable periods.
(b)
The provider must keep financial and supporting documents,
statistical records, and any other records pertinent to the Medicaid services
for which a claim or TAFI report was submitted to ECI or its agent. The records
and documents must be kept for a minimum of five years after the end of the
contract period or for five years after the end of the federal fiscal year
in which services were provided (if a provider agreement/contract has no specific
termination date in effect). If any litigation, claim, or audit involving
these records begins before the five year period expires, the provider must
keep the records and documents for not less than five years or until all litigation,
claims, or audit finds are resolved. The case is considered resolved when
a final order is issued in litigation, or ECI and provider enter into a written
agreement. In this section, contract period means the beginning date through
the ending date specified in the original agreement/contract; extensions are
considered separate contract periods.
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
August 16, 1999.
TRD-9905167
Donna Samuelson
Deputy Executive Director
Interagency Council on Early Childhood Intervention
Earliest possible date of adoption: September 26, 1999
For further information, please call: (512) 424-6750