Part 1.
TEXAS DEPARTMENT OF HUMAN SERVICES
Chapter 15.
MEDICAID ELIGIBILITY
The Texas Department of Human Services (DHS) proposes to amend §15.442
and §15.503, concerning resources and budgets and payment plans, in its
Medicaid Eligibility chapter. The purpose of the amendments is to ensure compliance
with federal law concerning the treatment of annuities, and to implement an
option available under federal law that requires an institutionalized spouse
to divert income to a community spouse before the institutionalized spouse
may request that the protection of the couple's resources be expanded.
The proposed amendment to §15.442 clarifies that an annuity purchased
by a person is a countable resource for Medicaid eligibility purposes unless
the annuity meets certain criteria, and removes the current requirement that
an annuity purchase be considered a transfer of assets if the annuity does
not name the state of Texas, DHS, or its successor agency as residuary beneficiary.
The amendment is in accord with recent interpretive guidance provided by the
federal Centers for Medicare and Medicaid Services (CMS). CMS has recently
informed states that the federal regulation at 20 Code of Federal Regulations
(CFR) §416.1201 requires an annuity to be counted as a resource if it
can be sold. CMS has also clarified that the purchase of an annuity is not
necessarily a transfer of assets for which a penalty period of Medicaid ineligibility
may be imposed merely because the annuity does not name the state as residuary
beneficiary. The amendment to §15.442(g) would also implement an option
available to the state under §1902(r)(2) of the Social Security Act (42
U.S.C. §1396a(r)(2)) to be less restrictive in the counting of annuities
than that which is otherwise required by 20 CFR 416.1201. Under this option,
DHS would not count as a resource an annuity that meets the criteria described
in the proposal at §15.442(g)(1).
The proposed amendment to §15.503 relates to the procedure described
in §1924(d) of the Social Security Act (42 U.S.C. §1396r-5) for
increasing the amount of a married couple's resources that are not counted
in determining the institutionalized spouse's eligibility for Medicaid, in
order to protect income for the spouse who is remaining in the community (the
community spouse). The amendment requires that an institutionalized spouse
who applies for Medicaid must first divert income to his or her community
spouse (who is not applying for Medicaid), before the institutionalized spouse
may request expansion of the amount of the couple's resources that would be
protected from consideration in evaluating the institutionalized spouse's
Medicaid eligibility. This has been referred to as the "income first" method
for determining the extent of protection of the couple's assets. The United
States Supreme Court has found this method to be permissible under federal
law in the case of
Wisconsin Dept. of Health and
Family Svcs. v. Blumer
, 534 U.S. 473 (2002). DHS proposes to implement
this change as a Medicaid cost savings measure, and to help ensure that limited
Medicaid dollars are more likely to be available to those truly in need of
the assistance. The amendment also clarifies the established methodology DHS
follows to calculate the amount of a couple's resources that is subject to
protection.
Gordon Taylor, Chief Financial Officer, has determined that, for the first
five-year period the proposed sections are in effect, there are fiscal implications
for state government as a result of enforcing or administering the sections.
The effect on state government for the first five-year period is an estimated
reduction in cost. However, DHS lacks sufficient data to accurately estimate
the cost savings. DHS has not found that there would be any fiscal implications
for local government as a result of enforcing or administering the sections.
Bettye M. Mitchell, Deputy Commissioner for Long Term Care, 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 is increased
clarity in the Medicaid eligibility requirements for annuitants, and the preservation
of limited Medicaid dollars for those truly in need of the assistance. There
is no adverse economic effect on small or micro businesses as a result of
enforcing or administering the sections, because the proposed amendments relate
only to financial status requirements for individuals to become eligible to
receive Medicaid benefits. There is no anticipated economic cost to persons
who are required to comply with the proposed sections. There is no anticipated
effect on local employment in geographic areas affected by these sections.
Questions about the content of this proposal may be directed to John Stockton
at (512) 438- 3225 in DHS's Long Term Care-Policy section. Written comments
on the proposal may be submitted to Supervisor, Rules Unit-141, Texas Department
of Human Services E-205, P.O. Box 149030, Austin, Texas 78714-9030, within
30 days of publication in the
Texas Register
.
Under Government Code, §2007.003(b), DHS has determined that Chapter
2007 of the Government Code does not apply to these rules. The changes these
rules make do not implicate a recognized interest in private real property.
Accordingly, DHS is not required to complete a takings impact assessment regarding
these rules.
These Medicaid eligibility rules are proposed by DHS, subject to the subsequent
transfer of rulemaking authority to HHSC. DHS is currently scheduled to transition
sometime in 2004 into two successor agencies, the existing Texas Health and
Human Services Commission (HHSC) and a new agency, the Texas Department of
Aging and Disability Services (DADS).
This reorganization is mandated by House Bill 2292, 78th Leg., R.S. (2003).
At the inception of operations of DADS, the authority to adopt all rules for
the operation and provision of health and human services by DADS will lie
with HHSC. In addition, the statutory reorganization mandates the transfer
to HHSC of the policy, rulemaking, and operational authority, within an eligibility
services division, for eligibility determinations for all health and human
services programs. These changes may result in the migration of these rules
from one title of the Texas Administrative Code to another or other changes.
Subchapter D. RESOURCES
40 TAC §15.442
The amendment is proposed under the Human Resources Code,
Chapters 22 and 32, which authorizes DHS to administer public and medical
assistance programs, and under Government Code, §531.021, which provides
the Texas Health and Human Services Commission with the authority to administer
federal medical assistance funds.
The amendment affects the Human Resources Code, §§22.0001-22.040
and §§32.001-32.067.
§15.442.Personal Property.
(a) - (f)
(No change.)
(g)
Annuities. A
person
[
(1)
An employment-related annuity is not a countable resource.
A
nonemployment-related
[
(A)
is irrevocable;
(B)
pays out principal in equal
monthly installments and pays out interest in either equal monthly installments
or in amounts that result in increases of the monthly installments at least
annually;
(C)
is guaranteed to return within
the person's life expectancy at least the person's principal investment plus
a reasonable amount of interest (based on prevailing market interest rates
at the time of the annuity purchase, as determined by DHS);
(D)
names the state of Texas, DHS,
or DHS's successor agency as the residual beneficiary of amounts payable under
the annuity contract, not to exceed any Medicaid funds expended on the person
during his lifetime; and
(E)
is issued by an insurance company
licensed and approved to do business in the state of Texas.
(2)
Income from an annuity that is not a countable resource
under paragraph (1) of this subsection is treated in accordance with §15.455(d)
of this chapter (relating to Unearned Income). An annuity that is a countable
resource under paragraph (1) of this subsection and that does not meet the
criterion described in paragraph (1)(C) of this subsection is also a transfer
of assets. The date of the transfer of assets is the date of the annuity purchase
or, if applicable, the date that the annuity contract was last amended in
exchange for consideration. DHS determines the penalty period based on the
amount payable under the annuity contract during that portion of the guarantee
period of the annuity that is after the date the person is reasonably expected
to die.
[
[
[
[
(3)
A revocable annuity that is a countable resource under
paragraph (1) of this subsection is valued according to the amount refundable
upon revocation. A transfer of assets occurs if a person sells a revocable
annuity for less than this amount. An irrevocable annuity that is a countable
resource under paragraph (1) of this subsection is valued according to its
fair market value. DHS presumes that the fair market value of such an annuity
is 80% of its total remaining payout. A person may overcome this presumption
by providing credible evidence to the contrary. If, however, the annuity contract
by its terms is non-negotiable, the total remaining payout is a transfer of
assets, as provided by §15.435(g)(3) of this chapter (relating to Liquid
Resources). A transfer of assets also occurs if a person sells an irrevocable
annuity for less than the purchase price (that is, the total principal invested)
minus the amount of principal that has already been paid.
[
(4)
The requirement in paragraph
(1)(D) of this subsection does not apply to an annuity purchased by or for
a person who is a "community spouse," as described in §15.503 of this
chapter (relating to Protection of Spousal Income and Resources). As provided
by §15.430(d)(2)(A) of this chapter (relating to Transfer of Assets),
the purchase of an annuity by the institutional spouse is not a transfer of
assets on the basis that the community spouse is the annuitant.
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 June 18, 2004.
TRD-200404018
Carey Smith
Deputy Commissioner, Legal Services
Texas Department of Human Services
Earliest possible date of adoption: August 1, 2004
For further information, please call: (512) 438-3734
40 TAC §15.503
The amendment is proposed under the Human Resources Code,
Chapters 22 and 32, which authorizes DHS to administer public and medical
assistance programs, and under Government Code, §531.021, which provides
the Texas Health and Human Services Commission with the authority to administer
federal medical assistance funds.
The amendment affects the Human Resources Code, §§22.0001-22.040
and §§32.001-32.067.
§15.503.Protection of Spousal Income and Resources.
(a) - (i)
(No change.)
(j)
Formula for increased PRA at appeal.
(1)
In nursing facility and waiver cases with a community spouse,
the client
(institutionalized spouse or waiver applicant/recipient)
can
make a request or file an
appeal to increase the protected
resource amount (PRA) to produce additional income for the
community
spouse.
This option is available only after the client diverts
all of his or her available income (that is, gross income minus allowable
deductions) to the community spouse, and only if the community spouse's resulting
total income is less than the minimum monthly maintenance needs allowance
(MMMNA).
The
eligibility specialist or
hearing officer may
then increase the PRA to
an amount that is
[
(2)
The couple can protect
an amount of
[
(3)
To determine the amount of the increased PRA, the
eligibility specialist or
hearing officer determines the current interest
rate of a one-year CD as published in the local
newspaper
[
(4)
The amount of resources to be protected is determined by
using the
methodology described
[
(A)
Subtract
from the amount of the MMMNA
the community
spouse's
monthly
[
(B)
Multiply
by 12 the
additional monthly income
needed by the community spouse (from subparagraph (A) of this paragraph)
[
(C)
Multiply
by 100 the
annual income needed by
the community spouse (from subparagraph (B) of this paragraph) [
(D)
Divide the product from subparagraph (C) of this paragraph
by the interest rate
described in paragraph (3) of this subsection
[
(E)
The expanded PRA may not exceed the value of the couple's
combined countable resources as of the first month of entry
by the client
to a medical care facility for a continuous stay
, or, if applicable,
as of the first month of application by the client to a waiver program
.
(5)
When determining the post-eligibility applied income or
co-payment of the client
[
(k)
Spousal impoverishment provisions do not apply in the case
of void or annulled marriages. Clients with void marriages or who have obtained
a court annulment of their marriage are treated as though they were always
individuals. In the instance of a divorce, spousal impoverishment provisions
apply through the end of the calendar month
of the court order granting
the divorce
[
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 June 18, 2004.
TRD-200404019
Carey Smith
Deputy Commissioner, Legal Services
Texas Department of Human Services
Earliest possible date of adoption: August 1, 2004
For further information, please call: (512) 438-3734
The Texas Department of Human Services (DHS) proposes to amend §19.405,
concerning additional requirements for trust funds in Medicaid-certified facilities; §19.2302,
concerning requirements for a contracted Medicaid facility; and §19.2312,
concerning surety bonds or letters of credit, in its Nursing Facility Requirements
for Licensure and Medicaid Certification chapter.
The purpose of the amendment to §19.405 is to correct the references
to the Code of Federal Regulations that require handling trust fund monthly
benefits in Medicaid-certified facilities. The amendment to §19.2302
adds an applicable rule, 1 Texas Administrative Code (TAC) §371.212,
Case Mix Classification System, as Medicaid-certified facilities must comply
with the requirements of the Texas Health and Human Services Commission (HHSC)
for utilization review. The amendment to §19.2312 makes it consistent
with HHSC rules on the same subject and clarifies for facilities the types
of reports they have to file before they can furnish a surety bond or a letter
of credit upon a change of ownership or termination of a contract.
Gordon Taylor, Chief Financial Officer, has determined that, for the first
five-year period the proposed sections are in effect, there are no fiscal
implications for state or local government as a result of enforcing or administering
the sections.
Bettye M. Mitchell, Deputy Commissioner for Long Term Care, 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 is to ensure
the accuracy of information available to the public and enhance the public's
ability to locate desired information referenced in the rules. The rules will
clarify where facilities are to mail their cost reports and ensure consistency
between DHS and HHSC rules as they relate to vendor hold and HHSC Rate Analysis
nursing facility reporting requirements. There is no adverse economic effect
on small or micro businesses as a result of enforcing or administering the
sections, because the amendments impose no additional costs to the facilities
and they are already subject to these requirements under HHSC rules. There
is no anticipated economic cost to persons who are required to comply with
the proposed sections. There is no anticipated effect on local employment
in geographic areas affected by these sections.
Questions about the content of this proposal may be directed to Marcia
Bowen at (512) 438- 2118 in DHS's Long-Term Care Regulatory Policy section.
Written comments on the proposal may be submitted to Supervisor, Rules Unit-161,
Texas Department of Human Services E-205, P.O. Box 149030, Austin, Texas 78714-9030,
within 30 days of publication in the
Texas Register
.
Under Government Code, §2007.003(b), DHS has determined that Chapter
2007 of the Government Code does not apply to these rules. The changes these
rules make do not implicate a recognized interest in private real property.
Accordingly, DHS is not required to complete a takings impact assessment regarding
these rules.
These rules are proposed by DHS, subject to the subsequent transfer of
rulemaking authority to the Texas Health and Human Services Commission (HHSC).
DHS is currently scheduled to transition sometime in 2004 into two successor
agencies, the existing HHSC and a new agency, the Texas Department of Aging
and Disability Services (DADS).
This reorganization is mandated by House Bill 2292, 78th Legislature, Regular
Session (2003).
At the inception of operations of DADS, the authority to adopt all rules
for the operation and provision of health and human services by DADS will
lie with HHSC. These changes may result in the migration of these rules from
one title of the Texas Administrative Code to another or other changes.
Subchapter E. RESIDENT RIGHTS
40 TAC §19.405
The amendment is proposed under the Human Resources Code,
Chapters 22 and 32, which authorizes DHS to administer public and medical
assistance programs, and under Government Code, §531.021, which provides
the Texas Health and Human Services Commission with the authority to administer
federal medical assistance funds.
The amendment affects the Human Resources Code, §§22.0001-22.040
and §§32.001-32.067.
§19.405.Additional Requirements for Trust Funds in Medicaid-certified Facilities.
(a) - (n)
(No change.)
(o)
Handling of monthly benefits. If the Social Security Administration
has determined that a Title II and Title XVI
Supplemental
[
(p) - (r)
(No change.)
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 June 18, 2004.
TRD-200404016
Carey Smith
Deputy Commissioner, Legal Services
Texas Department of Human Services
Earliest possible date of adoption: August 1, 2004
For further information, please call: (512) 438-3734
40 TAC §19.2302, §19.2312
The amendments are proposed under the Human Resources Code,
Chapters 22 and 32, which authorizes DHS to administer public and medical
assistance programs, and under Government Code, §531.021, which provides
the Texas Health and Human Services Commission with the authority to administer
federal medical assistance funds.
The amendments affect the Human Resources Code, §§22.0001-22.040
and §§32.001-32.067.
§19.2302.Requirements for a Contracted Medicaid Facility.
(a)-(b)
(No change.)
(c)
Each NF must comply with the Texas Health and Human Services
Commission's (HHSC's) utilization review requirements as provided in
1 TAC §371.212 (relating to Case Mix Classification System)
[
(d)-(p)
(No change.)
§19.2312.Surety Bonds or Letters of Credit.
(a)
(No change.)
(b)
At its sole option, the Texas Department of Human Services
(DHS) may allow the prior owner to obtain a surety bond or an irrevocable
letter of credit (collateral) and release the vendor payments on hold. Money
owed DHS by the prior owner for any reason will be recovered through the surety
bond or the letter of credit. Usually, the surety bond equals the average
monthly vendor payments paid to the facility. Facilities terminating a contract
for long-term care services may furnish a surety bond or letter of credit
only if
:
(1)
all required long-term care facility cost reports
have been filed with
the Texas Health and Human Services Commission (HHSC)
Rate Analysis Department;
(2)
all required long-term care
facility staffing and compensation reports have been filed with HHSC's Rate
Analysis Department; and
(3)
funds identified for recoupment from 1
TAC §355.308(n) or (o) or both (relating to Direct Care Staff Rate Component)
have been repaid to HHSC or its designee
[
(c)
If an acceptable surety bond or letter of credit
is presented to DHS, the vendor payments may be released. Facilities must
ensure that this bond or irrevocable letter of credit is in a format acceptable
to DHS, and does not include requirements that DHS, as a condition of receiving
payment, either:
(1)
return the original bond or letter; or
(2)
submit to any draft requirement of an irrevocable letter
of credit or surety bond, in addition to DHS's letter demanding payment.
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 June 18, 2004.
TRD-200404017
Carey Smith
Deputy Commissioner, Legal Services
Texas Department of Human Services
Earliest possible date of adoption: August 1, 2004
For further information, please call: (512) 438-3734
40 TAC §§20.101 - 20.112
(Editor's note: The text of the following sections proposed for
repeal will not be published. The sections may be examined in the offices
of the Texas Department of Human Services or in the Texas Register office,
Room 245, James Earl Rudder Building, 1019 Brazos Street, Austin.)
The Texas Department of Human Services (DHS) proposes
to repeal its Cost Determination Process chapter (Chapter 20), consisting
of §§20.101-20.112, concerning the cost determination process for
providers of contracted client services. The purpose of the repeals is to
remove the rules from DHS's rule base. They are duplicated in the rules of
the Texas Health and Human Services Commission (HHSC) at 1 Texas Administrative
Code Chapter 355 and will no longer be needed in DHS's rule base after the
agency's transformation into the Department of Aging and Disability Services--mandated
by House Bill 2292, 78th Legislature, Regular Session (2003)--takes place
on September 1, 2004.
Gordon Taylor, Chief Financial Officer, has determined that, for the first
five-year period the proposed repeals are in effect, there are no fiscal implications
for state or local government as a result of repealing the sections.
Bettye M. Mitchell, Deputy Commissioner for Long Term Care, has determined
that, for each year of the first five years the repeals are in effect, the
public benefit anticipated as a result of repealing the sections is that only
one set of rules will exist at HHSC for all rate determination matters, rather
than having a duplicate set of rules in DHS's and HHSC's rule bases. There
is no adverse economic effect on small or micro businesses, or on businesses
of any size, as a result of repealing the sections, because the repeals affect
duplicative rules and impose no additional requirements for provider agencies.
There is no anticipated economic cost to persons who are required to comply
with the proposed repeals. There is no anticipated effect on local employment
in geographic areas affected by these repeals.
Questions about the content of this proposal may be directed to Carolyn
Pratt at (512) 491- 1359 in HHSC's Rate Analysis Department. Written comments
on the proposal may be submitted to Supervisor, Rules Unit-193, Texas Department
of Human Services E-205, P.O. Box 149030, Austin, Texas 78714-9030, within
30 days of publication in the
Texas Register
.
Under Government Code, §2007.003(b), DHS has determined that Chapter
2007 of the Government Code does not apply to these repeals. The changes these
repeals make do not implicate a recognized interest in private real property.
Accordingly, DHS is not required to complete a takings impact assessment regarding
these repeals.
The repeals are proposed under the Human Resources Code, Chapter
22, which authorizes DHS to administer public assistance programs.
The repeals implement the Human Resources Code, §§22.0001-22.040.
§20.101.Introduction.
§20.102.General Principles of Allowable and Unallowable Costs.
§20.103.Specifications for Allowable and Unallowable Costs.
§20.104.Revenues.
§20.105.General Reporting and Documentation Requirements, Methods, and Procedures.
§20.106.Basic Objectives and Criteria for Audit and Desk Review of Cost Reports.
§20.107.Notification of Exclusions and Adjustments.
§20.108.Determination of Inflation Indices.
§20.109.Adjusting Reimbursement When New Legislation, Regulations, or Economic Factors Affect Costs.
§20.110.Informal Reviews and Formal Appeals.
§20.111.Administrative Contract Violations.
§20.112.Attendant Compensation Rate Enhancement
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 June 18, 2004.
TRD-200404011
Carey Smith
Deputy Commissioner, Legal Services
Texas Department of Human Services
Earliest possible date of adoption: August 1, 2004
For further information, please call: (512) 438-3734
40 TAC §41.114
(Editor's note: The text of the following section proposed for
repeal will not be published. The section may be examined in the offices of
the Texas Department of Human Services or in the Texas Register office, Room
245, James Earl Rudder Building, 1019 Brazos Street, Austin.)
The Texas Department of Human Services (DHS) proposes
to repeal §41.114, concerning payment rates for the consumer directed
services payment option, in its Vendor Fiscal Intermediary Payments chapter.
The purpose of the repeal is to remove the rule from DHS's rule base. It is
duplicated in the rules of the Texas Health and Human Services Commission
(HHSC) at 1 Texas Administrative Code Chapter 355 and will no longer be needed
in DHS's rule base after the agency's transformation into the Department of
Aging and Disability Services-- mandated by House Bill 2292, 78th Legislature,
Regular Session (2003)--takes place on September 1, 2004.
Gordon Taylor, Chief Financial Officer, has determined that, for the first
five-year period the proposed repeal is in effect, there are no fiscal implications
for state or local government as a result of repealing the section.
Bettye M. Mitchell, Deputy Commissioner for Long Term Care, has determined
that, for each year of the first five years the repeal is in effect, the public
benefit anticipated as a result of repealing the section is that only one
set of rules will exist at HHSC for all rate determination matters, rather
than having a duplicate set of rules in DHS's and HHSC's rule bases. There
is no adverse economic effect on small or micro businesses, or on businesses
of any size, as a result of repealing the section, because the repeal affects
duplicative rules and imposes no additional requirements. There is no anticipated
economic cost to persons who are required to comply with the proposed repeal.
There is no anticipated effect on local employment in geographic areas affected
by the repeal.
Questions about the content of this proposal may be directed to Carolyn
Pratt at (512) 491- 1359 in HHSC's Rate Analysis Department. Written comments
on the proposal may be submitted to Supervisor, Rules Unit-193, Texas Department
of Human Services E-205, P.O. Box 149030, Austin, Texas 78714-9030, within
30 days of publication in the
Texas Register
.
Under Government Code, §2007.003(b), DHS has determined that Chapter
2007 of the Government Code does not apply to this repeal. The change this
repeal makes does not implicate a recognized interest in private real property.
Accordingly, DHS is not required to complete a takings impact assessment regarding
the repeal.
The repeal is proposed under the Human Resources Code, Chapter
22, which authorizes DHS to administer public assistance programs.
The repeal implements the Human Resources Code, §§22.0001-22.040.
§41.114.Consumer Directed Services Payment Option.
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 June 18, 2004.
TRD-200404012
Carey Smith
Deputy Commissioner, Legal Services
Texas Department of Human Services
Earliest possible date of adoption: August 1, 2004
For further information, please call: (512) 438-3734
Subchapter F. CLAIMS PAYMENT AND DOCUMENTATION
40 TAC §47.5902
(Editor's note: The text of the following section proposed for
repeal will not be published. The section may be examined in the offices of
the Texas Department of Human Services or in the Texas Register office, Room
245, James Earl Rudder Building, 1019 Brazos Street, Austin.)
The Texas Department of Human Services (DHS) proposes
to repeal §47.5902, concerning reimbursement methodology for primary
home care, in its Contracting to Provide Primary Home Care chapter. The purpose
of the repeal is to remove the rule from DHS's rule base. It is duplicated
in the rules of the Texas Health and Human Services Commission (HHSC) at 1
Texas Administrative Code Chapter 355 and will no longer be needed in DHS's
rule base after the agency's transformation into the Department of Aging and
Disability Services-- mandated by House Bill 2292, 78th Legislature, Regular
Session (2003)--takes place on September 1, 2004.
Gordon Taylor, Chief Financial Officer, has determined that, for the first
five-year period the proposed repeal is in effect, there are no fiscal implications
for state or local government as a result of repealing the section.
Bettye M. Mitchell, Deputy Commissioner for Long Term Care, has determined
that, for each year of the first five years the repeal is in effect, the public
benefit anticipated as a result of repealing the section is that only one
set of rules will exist at HHSC for all rate determination matters, rather
than having a duplicate set of rules in DHS's and HHSC's rule bases. There
is no adverse economic effect on small or micro businesses, or on businesses
of any size, as a result of repealing the section, because the repeal affects
duplicative rules and impose no additional requirements on provider agencies.
There is no anticipated economic cost to persons who are required to comply
with the proposed repeal. There is no anticipated effect on local employment
in geographic areas affected by the repeal.
Questions about the content of this proposal may be directed to Carolyn
Pratt at (512) 491- 1359 in HHSC's Rate Analysis Department. Written comments
on the proposal may be submitted to Supervisor, Rules Unit-193, Texas Department
of Human Services E-205, P.O. Box 149030, Austin, Texas 78714-9030, within
30 days of publication in the
Texas Register
.
Under Government Code, §2007.003(b), DHS has determined that Chapter
2007 of the Government Code does not apply to this repeal. The change this
repeal makes does not implicate a recognized interest in private real property.
Accordingly, DHS is not required to complete a takings impact assessment regarding
the repeal.
The repeal is proposed under the Human Resources Code, Chapter
22, which authorizes DHS to administer public assistance programs.
The repeal implements the Human Resources Code, §§22.0001-22.040.
§47.5902.Reimbursement Methodology for Primary Home Care.
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 June 18, 2004.
TRD-200404013
Carey Smith
Deputy Commissioner, Legal Services
Texas Department of Human Services
Earliest possible date of adoption: August 1, 2004
For further information, please call: (512) 438-3734
Subchapter H. ELIGIBILITY
40 TAC §§48.2911 - 48.2915, 48.2918, 48.2920, 48.2921, 48.2928
The Texas Department of Human Services (DHS) proposes to
amend §§48.2911, concerning family care; 48.2912, concerning congregate
and home-delivered meals; 48.2913, concerning adult foster care; 48.2914,
concerning special services to persons with disabilities; 48.2918, concerning
eligibility for primary home care; 48.2920, concerning residential care; 48.2921,
concerning emergency care; and 48.2928, concerning emergency response services;
and proposes new §48.2915, concerning day activity and health services,
in its Community Care for Aged and Disabled chapter.
The primary purpose of the amendments is to replace rule language referring
to specific functional eligibility scores on DHS's current community care
assessment instrument (Form 2060) with language that more generally explains
how DHS determines functional eligibility, in anticipation of the implementation
of a new assessment instrument. Pursuant to Rider 31 of DHS's appropriations
in the 2004-2005 General Appropriations Act, DHS is developing a new community
care assessment instrument that will replace the current Form 2060; therefore,
references to the current Form 2060 must be deleted to eliminate possible
conflict with the new form and its scoring system. Additionally, the amendments
to §48.2911 and §48.2918 remove obsolete language; update the terminology
regarding client status from "Priority 1" to "priority;" and add state schools,
state hospitals, jails, and prisons to the list of settings in which family
care, primary home care, and community attendant care services cannot be provided.
These additions are not changes, but rather clarify existing policy. The amendment
to §48.2918 also replaces the requirement for a physician's diagnosis
to substantiate the client's medical condition with a requirement for a signed
and dated practitioner's statement that the client has a current medical need
for assistance with personal care tasks and other activities of daily living,
and eliminates prior approval of medical need for primary home care by the
department regional nurse. The latter changes to §48.2918 make the eligibility
rule consistent with the provider agency rules in DHS's Chapter 47 (Contracting
to Provide Primary Home Care).
New §48.2915 places the Day Activity and Health Services (DAHS) eligibility
rule, currently in DHS's Chapter 98 (§98.201), with the other eligibility
rules in Chapter 48. The new rule retains the eligibility criteria in §98.201
and adds functional need criteria to the program's eligibility requirements.
The purpose of this addition is to help ensure that program resources are
used for individuals in the greatest need of services. The new rule also stipulates
that clients receiving DAHS on the effective date of the rule may continue
to receive services until DHS assesses the client's level of functional need.
Gordon Taylor, Chief Financial Officer, has determined that, for the first
five-year period the proposed sections are in effect, there are fiscal implications
for state government as a result of enforcing or administering the sections.
There are no anticipated fiscal implications for local governments as a result
of enforcing or administering the sections.
The effect on state government for the first five-year period the sections
are in effect is an estimated reduction in cost of $1,565,813 in fiscal year
(FY) 2005; $1,650,444 in FY 2006; $1,708,276 in FY 2007; $1,766,109 in FY
2008; and $1,823,921 in FY 2009.
Bettye M. Mitchell, Deputy Commissioner for Long Term Care, 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 is that program
eligibility requirements will be more clearly understandable, and limited
program resources will be preserved for individuals in the greatest need of
services. There may be an indirect adverse effect on businesses as a result
of enforcing or administering the sections because some businesses that currently
provide DAHS may lose Medicaid clients; however, the impact should not disproportionately
affect small or micro businesses. There is no anticipated economic cost to
persons who are required to comply with the proposed sections. There is no
anticipated effect on local employment in geographic areas affected by these
sections.
Questions about the content of this proposal may be directed to Marilyn
Eaton at (512) 438- 2936 in DHS's Long Term Care Services. Written comments
on the proposal may be submitted to Supervisor, Rules Unit-179, Texas Department
of Human Services E-205, P.O. Box 149030, Austin, Texas 78714-9030, within
30 days of publication in the
Texas Register
.
Under Government Code, §2007.003(b), DHS has determined that Chapter
2007 of the Government Code does not apply to these rules. The changes these
rules make do not implicate a recognized interest in private real property.
Accordingly, DHS is not required to complete a takings impact assessment regarding
these rules.
These eligibility rules are proposed by DHS, subject to the subsequent
transfer of rulemaking authority to the Texas Health and Human Services Commission
(HHSC). DHS is currently scheduled to transition sometime in 2004 into two
successor agencies, the existing HHSC and a new agency, the Department of
Aging and Disability Services (DADS).
This reorganization is mandated by House Bill 2292, 78th Legislature, Regular
Session (2003).
At the inception of operations of DADS, the authority to adopt all rules
for the operation and provision of health and human services by DADS will
lie with HHSC. In addition, the statutory reorganization mandates the transfer
to HHSC of the policy, rulemaking, and operational authority, within an eligibility
services division, for eligibility determinations for all health and human
services programs. These changes may result in the migration of these rules
from one title of the Texas Administrative Code to another or other changes.
The amendments and new section are proposed under the Human Resources
Code, Chapters 22 and 32, which authorizes DHS to administer public and medical
assistance programs, and under Government Code, §531.021, which provides
the Texas Health and Human Services Commission with the authority to administer
federal medical assistance funds.
The amendments and new section affect the Human Resources Code, §§22.0001-
22.040 and §§32.001-32.067.
§48.2911.Family Care.
(a)
To be eligible for family care, the applicant/client
must:
(1)
meet the income and resource
guidelines established by the department in §§48.2902, 48.2903,
48.2922, and 48.2923 of this title (relating to Income and Income Eligibles;
Determination of Countable Income; Resource Limits; and Countable Resources);
(2)
meet the minimum functional
need criteria as set by the department. The department uses a standardized
assessment instrument to measure the client's ability to perform activities
of daily living. This yields a score, which is a measure of the client's level
of functional need. The department sets the minimum required score for a client
to be eligible, which the department may periodically adjust commensurate
with available funding; and
(3)
be ineligible to receive attendant care
services funded through Medicaid.
[
(b)
If eligible, an applicant/client may receive
one or more of the following services:
(1)
personal care
;
[
(2)
household tasks
;
[
(3)
meal preparation
;
[
(4)
escort. [
(c)
[
(1)
a hospital;
(2)
a skilled nursing facility;
(3)
an intermediate care facility;
(4)
an assisted living facility
[
(5)
a foster care setting; [
(6)
a jail or prison;
(7)
a state school;
(8)
a state hospital; or
(9)
[
(d)
[
(1)
requires
[
(2)
lives in the same household as another individual receiving
family care
, community based alternatives personal assistance services,
community attendant services,
or primary home care;
(3)
receives
one or more of the following services (through
the department or other resources):
(A)
congregate or home-delivered meals
;
[
(B)
assistance with activities of daily living from
a home health aide
;
[
(C)
day activity and health services
;
[
(D)
special services to persons with disabilities
in adult day care
;
[
(4)
receives aid-and-attendance benefits from the Veterans
Administration; [
(5)
receives services through the department's In-home and
Family Support Program
; or
[
(6)
is determined, based upon the
functional assessment, to be at high risk of institutionalization without
family care.
[
(e)
The
[
(1)
The individual is completely unable to perform one or more
of the following activities without hands-on assistance from another person:
(A)
transferring himself into or out of bed or a chair or on
or off a toilet;
(B)
feeding himself;
(C)
getting to or using the toilet;
or
(D)
preparing a meal
.
[
[
(2)
During a normally scheduled service shift, no one is readily
available [
(3)
The [
(f)
A client with priority status
may receive no more than 42 hours of service per week.
(g)
A client without priority status
may receive no more than 50 hours of service per week.
§48.2912. Home-Delivered [
To be eligible for [
§48.2913.Adult Foster Care.
To be eligible for adult foster care, applicants and clients must
have the approval of the Community Care for Aged and Disabled unit supervisor
and meet the functional need criteria as set by the department. The department
uses a standardized assessment instrument to measure the client's ability
to perform activities of daily living. This yields a score, which is a measure
of the client's level of functional need. The department sets the minimum
required score for a client to be eligible, which the department may periodically
adjust commensurate with available funding
[
§48.2914.Special Services to Persons with Disabilities.
To be eligible for special services to persons with disabilities, clients
must
meet the functional need criteria as set by the department. The
department uses a standardized assessment instrument to measure the client's
ability to perform activities of daily living. This yields a score, which
is a measure of the client's level of functional need. The department sets
the minimum required score for a client to be eligible, which the department
may periodically adjust commensurate with available funding
[
§48.2915.Day Activity and Health Services.
To be eligible for day activity and health services (DAHS), an applicant/client
must:
(1)
be Medicaid eligible or meet the income and resource guidelines
established by the department in §§48.2902, 48.2903, 48.2922, and
48.2923 of this title (relating to Income and Income Eligibles; Determination
of Countable Income; Resource Limits; and Countable Resources);
(2)
meet the minimum functional need criteria as set by the
department. The department uses a standardized assessment instrument to measure
the client's ability to perform activities of daily living. This yields a
score, which is a measure of the client's level of functional need. The department
sets the minimum required score for a client to be eligible, which the department
may periodically adjust commensurate with available funding. Clients receiving
services on the effective date of this rule may continue to receive services
until the department assesses the client's level of functional need;
(3)
have a medical diagnosis, a related functional disability,
and physician's orders requiring care, monitoring, or intervention by a licensed
vocational nurse or a registered nurse; and
(4)
have one or more of the following personal care or restorative
needs that can be stabilized, maintained, or improved by participation in
DAHS:
(A)
Bathing, dressing, and grooming. The applicant/client may
need help with bathing, dressing, and routine hair and skin care.
(B)
Transfer and ambulation. The applicant/client may need
help with transferring from chair or commode or walking about.
(C)
Toileting. The applicant/client may need help with using
a bedpan, urinal, or commode; emptying a catheter or ostomy bag; or managing
incontinence of bowel or bladder. The applicant/client may require perineal
care or bowel or bladder training.
(D)
Feeding. The applicant/client may need feeding (for example,
gastric, NG tube, feeding pump) or help with eating.
(E)
Fluid intake. The applicant/client may need assistance
in maintaining adequate fluid intake.
(F)
Nutrition. The applicant/client may need therapeutic diet
or texture modification for treatment or control of an existing condition.
(G)
Medication. The applicant/client may require supervision
or administration of ordered medications or injectables.
(H)
Treatments. The applicant/client may require treatments
that include:
(i)
routine or frequent care for indwelling catheter;
(ii)
measurement of weight related to monitoring a specific
condition;
(iii)
assistance or supervision of ostomy care based on individual
needs;
(iv)
taking and recording of vital signs to monitor an existing
condition or medications being administered;
(v)
periodic testing of blood or urine for sugar/acetone content
or both;
(vi)
assistance with skin care including application of lotions,
observations, assessment, or treatment of skin conditions based on physician's
orders for prevention and healing decubiti and chronic skin conditions; and
(vii)
application of sterile dressings and elastic stockings
and bandages.
(I)
Restorative nursing procedures. The applicant/client requires
assistance with range-of- motion exercises (active or passive) or proper positioning.
(J)
Behavioral problems. The applicant/client may have behavioral
problems that can be managed by facility staff.
§48.2918.[
(a)
To be eligible
[
(1)
be eligible for Medicaid
in a community setting
[
(2)
meet the minimum functional need criteria as set by
the department. The department uses a standardized assessment instrument to
measure the client's ability to perform activities of daily living. This yields
a score, which is a measure of the client's level of functional need. The
department sets the minimum required score for a client to be eligible, which
the department may periodically adjust commensurate with available funding
[
(3)
have a medical need for assistance with personal care.
(A)
The client's medical condition must be [
(B)
Persons diagnosed with mental illness,
mental retardation, or both, are not considered to have established medical
need based solely on such diagnosis. The diagnoses
[
(4)
have a signed and dated
practitioner's statement that
includes a statement that the client has a current medical need for assistance
with personal care tasks and other activities of daily living
[
(5)
require at least six hours of
service
[
(A)
requires
[
(B)
lives in the same household as another individual receiving
[
(C)
receives
one or more of the following services (through
the department or other resources):
(i)
congregate or home-delivered meals
;
[
(ii)
assistance with activities of daily living
from a home health aide
;
[
(iii)
day activity and health services
;
[
(iv)
special services to persons with disabilities
in adult day care
;
[
(D)
receives aid-and-attendance benefits from the Veterans
Administration;
(E)
receives services through the department's In-home and
Family Support Program; [
(F)
receives services through the [
(G)
is determined, based upon the
functional assessment, to be at high risk of institutionalization without
primary home care or community attendant care services.
(b)
To receive services, the applicant/client must reside in
a place other than:
(1)
a hospital;
(2)
a skilled nursing facility;
(3)
an intermediate care facility; [
(4)
an assisted living facility;
(5)
a foster care setting;
(6)
a jail or prison;
(7)
a state school;
(8)
a state hospital; or
(9)
[
(c)
A client with priority status may receive no more
than 42 hours of service per week. A client without priority status may receive
no more than 50 hours of service per week
[
[
[
(d)
[
(1)
The individual is completely unable to perform one or more
of the following activities without hands-on assistance from another person:
(A)
transferring himself into or out of bed or a chair or on
off a toilet;
(B)
feeding himself;
(C)
getting to or using the toilet;
or
(D)
preparing
a
meal
.
[
[
(2)
During a
normally
[
(3)
The [
§48.2920.Residential Care.
(a)
Eligibility for residential care is based on the following
criteria:
(1)
(No change.)
(2)
the applicant must
meet the functional need criteria
as set by the department. The department uses a standardized assessment instrument
to measure the client's ability to perform activities of daily living. This
yields a score, which is a measure of the client's level of functional need.
The department sets the minimum required score for a client to be eligible,
which the department may periodically adjust commensurate with available funding
[
(3)-(4)
(No change.)
(b)-(d)
(No change.)
§48.2921.Emergency Care.
(a)
Eligibility for emergency care is based on the following
criteria.
(1)
(No change.)
(2)
The applicant:
(A)
(No change.)
(B)
meets the functional need criteria as set by the department.
The department uses a standardized assessment instrument to measure the client's
ability to perform activities of daily living. This yields a score, which
is a measure of the client's level of functional need. The department sets
the minimum required score for a client to be eligible, which the department
may periodically adjust commensurate with available funding
[
(3)
(No change.)
(b)-(c)
(No change.)
§48.2928.Emergency Response Services.
To be eligible for emergency response services, a
[
(1)
meet the functional need criteria as set
by the department. The department uses a standardized assessment instrument
to measure the client's ability to perform activities of daily living. This
yields a score, which is a measure of the client's level of functional need.
The department sets the minimum required score for a client to be eligible,
which the department may periodically adjust commensurate with available funding;
and
[
(2)
meet the
following
requirements [
(A)
[
(B)
[
(C)
[
(D)
[
(E)
[
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 June 18, 2004.
TRD-200404035
Carey Smith
Deputy Commissioner, Legal Services
Texas Department of Human Services
Earliest possible date of adoption: August 1, 2004
For further information, please call: (512) 438-3734
Subchapter H. DAY ACTIVITY AND HEALTH SERVICES (DAHS) CONTRACTUAL REQUIREMENTS
client
] may
purchase
a revocable or irrevocable
[
an
] annuity to
provide income
(a nonemployment-related annuity), or may receive the
benefits of an employment-related annuity that provides a return on prior
services, as part of or in similar manner to a pension or retirement plan
. [
An annuity can be revocable or irrevocable.
]
revocable
] annuity is
a countable resource
unless the annuity:
[
. An irrevocable
annuity is a transfer of assets if it does not pay back the principal (original
purchase price) to the client during his life expectancy. To qualify for exemption
from transfer of assets rules, an annuity must be issued by an insurance company
licensed and approved to do business in the state of Texas. The eligibility
specialist must review the terms of an annuity contract or agreement to determine
if the principal of the annuity is an available resource or considered a transfer
of assets.
]
To avoid a transfer of assets penalty, an annuity purchased
by or for the client must:
]
(A)
be irrevocable;]
(B)
pay out principal and interest
in equal monthly installments to the client in sufficient amounts that the
principal is paid out during the life expectancy of the client; and]
(C)
name the state of Texas, Texas
Department of Human Services or its successor agency as the residual beneficiary
of funds remaining in the annuity, not to exceed any Medicaid funds expended
on the client during his lifetime.]
The
average number of years of expected life remaining for the client must equal
or exceed the stated life of the annuity. If the client is not reasonably
expected to live longer than the guarantee period of the annuity, the client
will not receive fair market value for the annuity based on projected returns.
In this case, the annuity is not actuarilly sound and a transfer of assets
for less than fair market value of the premium has taken place to the extent
of the portion not anticipated to be repaid in the client's lifetime. The
penalty is assessed based on a transfer of assets that is considered to have
occurred at the time the annuity was purchased, minus any principal paid to
the client prior to the file date for Medicaid benefits.
]
Subchapter F. BUDGETS AND PAYMENT PLANS
a level
]
adequate to produce income
that equals
[
up to
], but
does
not exceed, the
MMMNA
[
monthly maintenance needs
allowance
].
additional
] resources equal to the dollar amount that must be deposited in a one-year
certificate
of deposit
(CD), at current interest rates, to produce
interest income equal to the difference between the
MMMNA
[
monthly maintenance needs allowance
] (in effect at the time of the
request or the
filing of the appeal) and other countable income not
generated by either spouse's countable resources. The couple is not required
to invest in the CD as a condition of eligibility.
paper
] or provided by a local bank [
that offers one-year CD's
].
The
eligibility specialist or
hearing officer then determines the
amount of resources required to produce income, at the specified interest
rate, that would increase the
community
spouse's income to the
MMMNA
[
monthly maintenance needs allowance
].
formula specified
]
in subparagraphs (A)
-(E)
[
through (D)
] of this paragraph.
This
methodology
[
formula
] is to be used to determine
the maximum amount of resources to be protected regardless of the actual income
the couple's
[
a
] resource may or may not be producing [
at the time of the original PRA or at the time of the appeal hearing
].
non-resource-producing
] income
from all sources other than resources of the couple
(including
any
income
that must first be
diverted by the client
as required by paragraph (1) of this subsection
[
, if any) from
the monthly maintenance needs allowance (MMNA
]). The
result
[
difference
] is
the
additional monthly income needed by the
community spouse.
by 12
]. The product equals
the
annual income needed
by the community spouse.
by 100
].
for a one-year CD
]. Do not use a percentage.
The result is the
expanded PRA, subject to subparagraph (E) of this paragraph.
co-pay
] and the amount available
for [
spousal
] diversion
to the community spouse
,
DHS
[
the caseworker
] uses the actual
income from the
resources if it is more than the amount of income that
[
dollar
amount being produced if the actual amount is in excess of the amount
]
a one-year CD would produce. However, if the actual amount
of income
from the resources
[
a resource produces
] is less than the
amount
of income that
a one-year CD would produce,
DHS
[
the caseworker
] uses the amount
of income that
a one-year
CD would produce.
in which the divorce is issued
].
Chapter 19.
NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION
Supplementary
] Security Income (SSI) benefit to which the recipient
is entitled should be paid through a representative payee, the provisions
in 20 Code of Federal Regulations (CFR),
§§404.2001-404.2065
[
§§404.1601- 404.1610
], for Old Age, Survivors,
and Disability Insurance benefits and 20 CFR,
§§416.601-416.665
[
§§419.601-419.690
], for SSI benefits apply.
Subchapter X. REQUIREMENTS FOR MEDICAID-CERTIFIED FACILITIES
the Texas Administrative Code (TAC), Title 1, Part 15, Chapter 371, Medicaid
Fraud and Abuse Program Integrity
], §371.213 (relating to Utilization
Review and Control Activities Performed by Texas Health and Human Services
Commission (Commission))
,
and §371.214 (relating to Texas
Index for Level of Effort (TILE) Assessments).
DHS
].
Chapter 20.
COST DETERMINATION PROCESS
Chapter 41.
VENDOR FISCAL INTERMEDIARY PAYMENTS
Chapter 47.
CONTRACTING TO PROVIDE PRIMARY HOME CARE
Chapter 48.
COMMUNITY CARE FOR AGED AND DISABLED
Family care applicants/clients
are eligible for services if they score at least 24 on the client needs assessment
questionnaire.
]
,
]
,
]
,
] and
Beginning July 1, 1992, the applicant/client
is eligible for no more than 50 hours of family care services a week (effective
May 1, 1993, 42 hours a week for a Priority 1 family care applicant/client).
]
(b)
] Family care services are provided
in a client's residence. A client is not eligible to receive family care services
while living in:
a personal
care home (institution)
];
or
]
(6)
] any other setting where sources
outside the family care program are available to provide care.
(c)
] The applicant/client must
require at least six hours of family care per week
to be eligible, unless
the applicant/client
[
. An applicant/client requiring fewer than
six hours per week may be eligible if he
]:
scores 30 or above and
]
family care [
is essential
] to provide respite to the caregiver
[
or to enable the applicant to remain in the community
];
,
]
,
]
,
] or
, whether or not any of these services
are purchased by the department; or
]
or
]
.
]
(d)
To be eligible for family
care, the individual must not be eligible to receive attendant care services
funded through Medicaid.]
Establishment of a priority level
is made by the
] community care case manager
establishes a priority
status for each client based on the functional assessment
[
and
is based on an assessment of the client's circumstances and on discussions
with the client and others actively involved with the client. A Priority 1
family care client is an individual who is dependent upon the services of
the family care attendant for the performance of certain personal care tasks
and whose health, safety, or well-being may be jeopardized if services on
a normally scheduled service shift were not provided
]. An individual
is considered
to have priority status
[
a Priority 1 family
care client
] if the following criteria are met
:
[
.
]
; or
]
(E)
taking self-administered prescribed
medications.]
who is capable of providing, and who is willing
] to
provide [
,
] the needed assistance other than the family care attendant.
DHS
] community care case manager determines
that there is a high likelihood the individual's health, safety, or well-being
would be jeopardized if family care services were not provided on a single
given shift.
Congregate and Home-delivered ] Meals.
congregate or
] home-delivered meals,
applicants and clients must
meet the functional need criteria as set
by the department. The department uses a standardized assessment instrument
to measure the client's ability to perform activities of daily living. This
yields a score, which is a measure of the client's level of functional need.
The department sets the minimum required score for a client to be eligible,
which the department may periodically adjust commensurate with available funding
[
score at least 20 on the client needs assessment questionnaire
].
Applicants/clients
must score at least 18 on the client needs assessment questionnaire and have
the approval of the CCAD unit supervisor, to be eligible for adult foster
care. Individuals receiving adult foster care on July 1, 1986, continue to
be eligible for services as long as they score nine on the client needs assessment
questionnaire. If these grandfathered clients discontinue receiving services,
they must meet an eligibility score of at least 18 in order to qualify for
future services
].
score
at least nine on the client needs assessment questionnaire
]. Applicants
may be admitted to the attendant services program only if their needs do not
exceed the program's available services.
Eligibility for ] Primary Home Care or Community Attendant Services .
Applicants/clients
]
for primary home care
or community attendant (CA)
services
, the
[
must meet all of the following eligibility criteria. The
] applicant/client must:
outside an institution
] or be eligible under the provisions of the Social
Security Act, §1929(b)(2)(B);
score 24 or above on the client needs assessment questionnaire
];
substantiated by symptoms and a physician's diagnosis(es). The medical condition
must be
] the cause of the client's functional impairment in performing
personal care tasks.
Although mental
illness and mental retardation are not considered medical conditions, they
] do not disqualify a client for eligibility as long as the client's
functional impairment is related to a coexisting medical condition;
physician's order for primary home care
]; and
primary home care
] per week. An applicant/client requiring fewer than
six hours
of service
per week may be eligible if
the applicant/client
[
he meets at least one of the following criteria
]:
scores at least 30 on the client
needs assessment questionnaire and
] primary home care
or community
attendant services
[
is essential
] to provide respite care
to the caregiver [
or to enable the applicant/client to remain in the
community
];
family care or
] primary home care
, community attendant services,
family care, or community based alternatives personal assistance services
;
,
]
,
]
,
] or
, whether or not any of these services
are purchased by the department; or
]
or
]
Texas Department of
Health's
] Medically Dependent Children Program (MDCP)
; or
[
.
]
or
]
(4)
] any other
setting where
[
environment where family members or
] sources outside the
primary home care program are available to provide personal care.
Beginning July 1, 1992,
an eligible applicant or client cannot receive more than 50 hours of primary
home care per week (effective May 1, 1993, 42 hours a week for a Priority
1 primary home care applicant or client)
].
(d)
Applicants must have prior
approval of medical need for primary home care from the department regional
nurse. Only initial prior approval of medical need is required for applicants
who have a medical condition causing functional impairment in personal care.
Annual prior approval by the department regional nurse is required for clients
who are eligible under the provisions of the Social Security Act, §1929(b).]
(e)
Services for eligible clients
are authorized for 12 months, with the exception of time-limited services
specified in subsection (d) of this section.]
(f)
]
The
[
Establishment
of a priority level is made by the
] community care case manager
establishes a priority status for each client based on the functional assessment
[
based on an assessment of the client's circumstances and on discussions
with the client and others actively involved with the client. A Priority 1
primary home care client is an individual who is dependent upon the services
of the primary home care attendant for the performance of certain personal
care tasks and whose health, safety, or well- being may be jeopardized if
services on a normally scheduled service shift were not provided
]. An
individual is considered
to have priority status
[
a Priority
1 primary home care client
] if the following criteria are met
:
[
.
]
; or
]
(E)
taking self-administered prescribed
medications.]
normal
] scheduled
service shift, no one is readily available [
who is capable of providing,
and who is willing
] to provide [
,
] the needed assistance
other than the [
primary home care
] attendant.
Texas Department of Human Services
] community
care case manager determines that there is a high likelihood the individual's
health, safety, or well-being would be jeopardized if [
primary home care
] services were not provided on a single given shift.
score at least 18 points on the client needs assessment questionnaire
];
demonstrates
a need for service by scoring at least 18 points on the client needs assessment
questionnaire
].
A
] client must
:
score at least 20 on the client needs assessment questionnaire
and
]
in paragraphs (1)-(5) of this section to be eligible for emergency response
services
]:
(1)
]
live
[
Live
] alone, be alone routinely for eight or more hours each day, or live
with an incapacitated individual who could not call for help or otherwise
assist the client in an emergency;
(2)
]
be
[
Be
]
mentally alert enough to operate the equipment properly, in the judgment of
the DHS caseworker;
(3)
]
have
[
Have
] a telephone with a private line, if the system requires a private
line to function properly;
(4)
]
be
[
Be
]
willing to sign a release statement that allows the responder to make a forced
entry into the client's home if he is asked to respond to an activated alarm
call and has no other means of entering the home to respond;
and
(5)
]
live
[
Live
] in a place other than a skilled institution,
assisted living
facility
[
personal care home
], foster care setting, or any
other setting where
24-hour
[
24 hour
] supervision is
available.
Chapter 98.
ADULT DAY CARE AND DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS