DADS CLASSPM, Section 2000, Case Management Agency (CMA)
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Health and Human Services Commission/Texas Department of Aging and Disability Services Community Living Assistance and Support Services Provider Manual Revision: 16-1 Effective: January 28, 2016 Section 2000 Case Management Agency (CMA) 2100 Case Management Responsibilities Revision 15-2; Effective November 20, 2015 Case management services are provided to all individuals receiving Community Living Assistance and Support Services (CLASS) program and Community First Choice (CFC) Personal Assistance Services/Habilitation (PAS/HAB) services in the CLASS) program. Individuals must select a CMA with a valid provider agreement that has its base of operation physically located in the geographic catchment area specified in the contract and is the catchment area in which the individual lives. Individuals who receive services in the CLASS program may request to transfer to another CMA at any time. As outlined in this section, the CMA is required to provide the following case management services on an ongoing basis: assist the individual as necessary to maintain Medicaid eligibility; conduct various tasks related to enrollment; perform functions related to service planning; monitor the provision of CLASS services; protect the individual's rights; intervene to assist individuals in crisis; and coordinate the individual's CLASS services with non-CLASS services as necessary through the employment of person-centered planning techniques. CLASS program services, as a whole, enhance an individual's integration into the community and prevent admission to an institution while maintaining and improving independent functioning. 2110 Base of Operation Revision 11-3; Effective November 18, 2011 CLASS program providers must have a base of operation that includes a physical location and normal operating hours in each geographic catchment area for which they have a contract to provide CLASS program services. 1. A base of operation is a place in which business, clerical or professional activities are conducted. Each base of operation must: o maintain individual records for the CLASS program contract in the catchment area; o maintain personnel records for personnel who provide CLASS program services to individuals served in the catchment area; o be staffed by qualified employees who have completed CLASS program training and can readily become familiar with the individuals being served in the catchment area; and o maintain adequate staff to provide services and to supervise the provision of services within the catchment area. 2. Providers must identify the base of operation's normal operating hours. If the base of operations is closed during its normal operating hours or between the hours of 8:00 a.m. and 5:00 p.m. Monday through Friday, the provider must: o post a notice in a visible location outside the base of operations to provide information regarding how to contact the person in charge; and o leave a message on an answering machine or similar electronic mechanism to provide information regarding how to contact the person in charge. 2120 CMA Staff Training Requirement Revision 12-1; Effective January 13, 2012
2121 Initial Training for Staff with Direct Contact Revision 13-2; Effective September 6, 2013 Direct contact for the purposes of this manual means face to face contact a minimum of one time per calendar year. Upon hire, all Case Management Agency (CMA) staff whose job functions might involve direct contact with individuals receiving Community Living Assistance and Support Services (CLASS) must complete one of the following within 60 calendar days of the employee beginning to provide CLASS program services: In-person CLASS Provider Training provided by the Health and Human Services Commission/Department of Aging and Disability Services (DADSHHSC/DADS); or Training developed by CMA that includes, at a minimum: o CLASS program overview; o Person-centered planning; o Philosophy and values of community integration; o Overview of related conditions and CLASS program eligibility criteria; o Service Planning Team (SPT) process; o Utilization Review process; o Consumer Directed Services; and o Individuals' rights and responsibilities including: . Fair hearing process; . CMA's complaints process; . Mandatory participation requirements; and . Abuse, neglect and exploitation characteristics and reporting information. The CMA could choose to conduct training at its location to meet the above requirements within 60 days of hiring the service provider. CMA staff who develop the curriculum used for initial training must have attended and successfully completed the CLASS Provider Training. The CMA must have a record to verify that the trainer has attended the CLASS Provider Training. The CMA may choose to send new employees to CLASS Provider Training at the next opportunity offered by DADSHHSC/DADS to further reinforce training provided by the CMA. Documentation of completion of required training must include, at a minimum: CLASS Provider Training completion certificate with the name of the employee, signed by DADSHHSC/DADS; or Written documentation of completion of CMA's training that includes: o Training topics covered; o Method of training (i.e., reading, video, discussion, etc.); o Name(s) and qualifications of instructor(s); o Name of the trainee; o Date the training was completed; o Signature and date of the instructor(s); and o Signature and date of the trainee verifying completion. If a CMA develops curriculum to meet CLASS training requirements, the curriculum and training materials used must be maintained by CMA and be available to DADSHHSC/DADS employees during a contract monitoring review. 2122 Initial and Annual Training for All CMA Staff Revision 13-2; Effective September 6, 2013 All Case Management Agency (CMA) staff must complete the training described below within 60 calendar days of employment and at least every 12 months thereafter: Abuse, Neglect and Exploitation (ANE) o review of the statute on ANE at Human Resources Code, Chapter 48, §48.002 (2, 3 and 4); o signs and symptoms of ANE; o reporting requirements of ANE; and o how to report abuse and neglect to DFPS at https://www.dfps.state.tx.us/Contact_us/report_abuse.asp www.dfps.state.tx.us/Contact_Us/report_abuse.asp. Rights and Responsibilities of Individuals o information about the rights of the individual who receives CLASS services as outlined in the DADS Consumer Rights and Services booklet; and o review of CLASS rules in Chapter 45, Subchapter C, §45.301 and §45.302 concerning the Rights and Responsibilities of an Individual. If a CMA develops curriculum to meet CLASS training requirements, the curriculum and training materials used must be maintained by CMA and available to DADSHHSC/DADS employees during a contract monitoring review. 2123 CMA Staff Training for Person-Centered Planning CMA staff responsible for completing the Individual Program Plan (IPP)(Form 8606) and the Individual Program Plan Addendum (IPPA)(Form 3629) must complete person-centered service planning training approved by HHSC according to this schedule: by June 1, 2017, if the staff person was hired on or before June 1, 2015; or within two years after the hire date, if the staff person was hired after June 1, 2015. 2200 Eligibility Revision 15-2; Effective November 20, 2015 The case manager is responsible for verifying the individual's eligibility for the CLASS program by ensuring the following criteria are met: The individual is financially eligible for Medicaid because the individual receives Supplemental Security Income (SSI) cash benefits or is determined by the Health and Human Services Commission (HHSC) to be financially eligible for Medicaid. The individual has been diagnosed prior to age 22 with a related condition as described in the Texas Approved Diagnostic Codes for Persons with Related Conditions. The individual has a qualifying adaptive behavior level of of II, III, or IV (i.e., moderate to extreme deficits in adaptive behavior) obtained by administering a standardized assessment of adaptive behavior. The individual demonstrates a need for CFC PAS/HAB; or receive at least one CLASS Program service per IPC year, and one CLASS service per month (case management visits meet this requirement). The individual has an Individual Plan of Care (IPC) cost for CLASS program services at or below $114,736.07. The individual is not enrolled in another Medicaid waiver program. The individual resides in theirindividual resides in his or her own home or family home. The Case Management Agency (CMA) must verify Medicaid eligibility on aeach monthly basis by monitoring the Medicaid Eligibility Service Authorization Verification (MESAV) system. The Medicaid eligibility must verify the individual is eligible in the month that is being checked. Documentation of this monthly verification of eligibility for Medicaid must be maintained by the CMA and available for review during contract monitoring visits.In addition, DADS informs CMA monthly in writing about the loss of Medicaid eligibility for any of the individuals assigned to the CMA. DADS provides the following information: individual's name; Medicaid number; and effective date of loss of Medicaid eligibility. When If the CMA receives notice of an individual's impending loss of Medicaid eligibility through MESAV, the CMA must work proactively with the individual/legally authorized representative (LAR) to ensure Medicaid eligibility is re-established as soon as possible. For individuals who lose Medicaid eligibility, the CMA must offer direct assistance to the individual/LAR as necessary to help the individual re-establish eligibility. The CMA must follow up with the individual/LAR at least every two weeks regarding and document progress toward completion of necessary steps until Medicaid eligibility is re-established or the individual is terminated from the CLASS program. Program services may be terminated if the individual does not meet any eligibility criteria as outlined in Title 40 of the Texas Administrative Code (TAC) §45.406. See Section 2400, Denial, Reduction, Suspension and Termination, for more information on termination of services. 2300 Service Planning Revision 15-2; Effective November 20, 2015 The case manager facilitates Service Planning Team (SPT) meetings. The SPT process uses a person-centered planning processes to develop a plan foremphasizes the provision of supports and services necessary for the individual's functioning and to maintain integration in the community. After all requirements for eligibility are met, and at least annually thereafter, the case manager, the applicant/individual/legally authorized representative (LAR), Direct Service Agency (DSA) representative(s) (as defined in Section 3300, Service Planning), and other people requested by the applicant/individual/LAR meet to develop a proposed Form 3621, CLASS/CFC – Individual Plan of Care (IPC). The case manager must use Form 3629, Individual Program Plan Addendum to document use of person-centered planning processes. The case manager, using the discovery process as the basis for collecting information, develops the person-centered plan with the individual, legally authorized representative (LAR), the CMA, DSA representative, and others, as requested by the individual or LAR. Examples of the discovery process include, but are not limited to: conversations with the individual, LAR and those who know the individual best, such as a provider staff, caregiver, family member and friend; a method called Planning Alternative Tomorrows with Hope (PATH); methods taught by The Learning Community for Person Centered Practices (TLCPCP);occur with the support of a group of people chosen by the individual (and the legally authorized representative (LAR) on the individual's behalf); and
The person-centered planning process accommodates the individual's style of interaction, communication and preferences regarding time and setting identify the individual’s strengths, preferences, support needs and desired outcomes; identify what is important to the individual; identify and document the individual’s current and preferred living arrangement; determine the Habilitation (HAB), Personal Assistance Services (PAS), Emergency Response Services (ERS) and Support Management needs of an individual; assess the individual's needs, functional impairments, ability to perform activities of daily living (ADLs), instrumental activities of daily living (IADLs) and health-related tasks; identify natural supports available to the individual and needed service system supports; document the individual’s preferences for when to receive CFC services; document the risks to the individual’s health and safety, as well as a plan to mitigate those risks; identify any special needs, requests or considerations staff should know when supporting this individual; and document the individual’s unmet needs. Additional guidance and information about person-centered planning can be found at http://www.learningcommunity.us. Meetings of the SPT to develop the enrollment IPC and the renewal IPC should be held in the individual’s own home or family home whenever possible. If it is not possible, the SPT must document why the meeting could not be held in the individual’s home. While individuals or their LAR may request the case manager meet in locations other than their own home/family home, case managers should remind them that meeting in the home allows the SPT the opportunity to determine if other needs of the individual may be met by through CLASS or CFC services. The enrollment and renewal IPC must be signed in person by the SPT. SPT activities to revise a current IPC may occur via conference call in lieu of a face-to-face meeting. Revisions of the current service plan may be signed by facsimile. The case manager is required to ensure that the service planning team develops a transportation plan if habilitation transportation is included on the IPC. Information on completing Form 3598, Individual Transportation Plan is available in the instructions. The proposed IPC must specify: the type of CLASS program services to be provided to the individual; the number of units of each CLASS program service; the number of units of each CFC service (except support management) the estimated annual cost of all CLASS program and CFC services; and other services or supports to be provided to the individual through sources other than the CLASS program. As part of the service planning process, the SPT will also develop an Individual Program Plan (IPP) on Form 8606, Individual Program Plan (IPP). An IPP is needed for each CLASS program service listed on the proposed IPC. Each IPP describes: CLASS program services to be provided; frequency of service provisions; observable and measurable goals and objectives; title of person responsible for goals and objectives; justification for services based on needs identified by the SPT; duration of services; and support services provided through non-waiver resources. Form 3629, Individual Program Plan Addendum is completed SPT notes are created by the case manager during the SPT meeting to document use of person-centered planning processes. The SPT notes also created by the case manager summarize the outcome of the meeting and must include, at a minimum: each service being requested by the SPT; planned service schedules for each service requested; units/amount of each service requested; and signature and date of each SPT member present at the meeting. If the individual requests a therapeutic service (e.g., occupational therapy, physical therapy, speech and language pathology, behavioral support, audiology, dietary service, auditory enhancement training or any specialized therapy), the case manager must initiate Form 8606-A, Therapy Justifications – Attachment to IPP, based on the deliberations of the SPT. The case manager must coordinate the completion of Attachment A with the appropriate professional. Since this professional is employed by, or contracts with, the DSA, assistance from the DSA is vital to ensure the case manager performs this function. The signature date of the professional on Attachment A cannot precede the date of the SPT meeting that identifies the individual’s need for the service or continuation of the need for the service. The case manager is responsible for initiating revisions to the individual's IPC and Individual Program Plan Addendum as determined necessary throughout each plan year. The case manager will submit all proposed IPCs and revised Individual Program Plan Addendum to DADSHHSC/DADS. The case manager on an ongoing basis must, on an ongoing basis, assist individuals in gaining access to needed CLASS services and other services and supports, including medical, social, and educational resources, regardless of the funding source for the services and supports. All requests from DADSHHSC/DADS related to the UR process must be submitted within the time frameperiod outlined in Section 5000. Effective January 16, 2017, the CMA will no longer receive the authorized IPC from HHSC/DADS. The CMA is responsible for providing a copy of the following documentation to all SPT members within 10 business days from DADS authorization, includingmembers including the financial management services agency (FMSA), if the individual receives a service through the Consumer Directed Services option: authorized Form 3621, CLASS/CFC — Individual Plan of Care; Form 8606, Individual Program Plan (IPP); SPT notes; Form 8606-A, Therapy Justifications — Attachment to IPP, if applicable; Form 3660, Request for Adaptive Aids, Medical Supplies, Minor Home Modifications or Dental Services/Sedation, if applicable; Form 3597, CLASS — Habilitation Training Plan, if applicable; and additional documentation as agreed upon by the SPT. 2310 Enrollment Revision 16-1; Effective January 28, 2016 At the time an applicant receives a written offer of a CLASS program vacancy from DADSHHSC/DADS, the applicant must select a Case Management Agency (CMA) within 30 calendar days after the date of the written offer from DADS. DADSHHSC/DADS notifies the selected CMA the applicant has chosen the agency to provide case management services. according to the DADS Selection Determination document. The CMA completes: Form 3657, Pre-Enrollment Assessment; Form 8507, Understanding Program Eligibility - CLASS/DBMD; assists the applicant with the application process for Medicaid eligibility, if needed;, and provides general information regarding the CLASS Medicaid waiver program to CLASS applicants. The case manager must provide the applicant/individual the CLASS Program brochures in English and Spanish. All applicable forms related to enrollment activities are included in the table at the end of this section.The case manager should also take advantage of this opportunity to describe the person- centered planning process, as described in Section 2300, that will be used to develop the Individual Program Plan Addendum. Upon notification that the applicant has selected the CMA, a case manager must be assigned to the applicant. The CMA must have a written process that ensures case managers are or can readily become familiar with individuals to whom they are not ordinarily assigned, but to whom they may be required to provide case management. The case manager must complete the following functions within 14 calendar days of the CMA's receipt of the Selection Determination document from DADSHHSC/DADS: provide applicant/legally authorized representative (LAR) with name and contact information, including an alternate contact in case of absence of the case manager; conduct an initial face-to-face, in-home visit with the applicant/LAR that must include providing an oral and written explanation of: o CLASS program services; o CFC services available in the CLASS program through the Medicaid State Plan, o CFC personal assistance services/habilitation (CFC PAS/HAB), which provides all the activities of habilitation, except habilitation transportation services; o CFC emergency response services (CFC ERS), which is provided as a CFC service; and o CFC support management; o the eligibility requirements for: CLASS Program services and CFC services using Form 8507 Understanding Program Eligibility- CLASS/DBMD o the mandatory participation requirements; o the Consumer Directed Services (CDS) option; o the complaint process; o information about cognitive rehabilitation therapy (CRT) and assistance for the individual to obtain a neurobehavioral or neuropsychological assessment and plan of care from a qualified professional using Medicaid State Plan, if appropriate; o Form 8601, Verification of Freedom of Choice, designating specifying choice of CLASS services over theinstead of institutional services in an Intermediate Care Facilities for Individuals with an Intellectual Disability or Related Conditions (ICF/IID); o provide information regarding voter registration, if the individual is age 18 or older; o determining how an individual meets criteria for Transition Assistance Services (TAS) if the individual is receiving institutional services: . ensuring the proper information is included on Form 8604, Transition Assistance Services (TAS) Assessment and Authorization; . sending the completed form to DADSHHSC/DADS for authorization with the proposed enrollment individual plan of care (IPC); . sending the authorized form to the TAS provider; and . including the TAS and the monetary amount authorized by DADSHHSC/DADS on the individual's proposed enrollment IPC; provide an oral and written explanation to the individual/LAR describing that the Direct Service Agency (DSA) may be requested to provide habilitation CFC PAS/HAB or out- of-home respite in a camp while the individual is temporarily staying outside the catchment area in which the individual resides, but within the state of Texas, as described in 40 Texas Administrative CodeTAC §45.702, including that the DSA may accept or decline the request; provide the following information regarding required use of the Electronic Visit Verification (EVV): o EVV will not change the services the individual receives. o The CFC PAS/HAB services provider will need the individual’s permission to use the telephone to call a toll-free number at the start and at the end of work. o EVV helps HHSC/DADS make sure the individual is receiving authorized services. o EVV is mandatory for all DSAs and individuals receiving services from a CFC PAS/HAB services provider, unless the individual receives services through the Consumer Directed Services (CDS) option. o Failure to cooperate will result in the suspension or termination of services. o If the individual does not have a telephone or does not want the CFC PAS/HAB services provider to use his telephone, a fixed verification device can be placed in the home, which is used only to verify the CFC PAS/HAB services provider’s start and end of work. o If the individual has additional questions, the case manager refers him to the selected DSA or FMSA for additional information on how EVV works; complete Form 3657; and verify residency to ensure the applicant lives in his own or family home that is located within the catchment area for which the CMA has a current Community Services Contract (Provider Agreement), to provide CLASS program services. The case manager must complete the following functions within two business days following the initial face-to-face assessment: evaluate the applicant's need for CFC PAS/HAB habilitation services; assist with Medicaid eligibility processes, as necessary; verify the individual is not enrolled in another 1915(c) Medicaid waiver program or any other mutually exclusive services or programs (See Appendix III, DADS Operated Program CLASS Mutually Exclusive ListServices); and provide the Direct Service Agency (DSA) with a completed Form 3657. Within 30 calendar days of notification by the DSA of DADSHHSC/DADS approval of diagnostic/functional eligibility for an individual as identified on Form 8578, Intellectual Disability/Related Condition Assessment, the case manager must convene the SPT to develop the enrollment Individual Plan of Care (IPC), Form 3621, CLASS/CFC – Individual Plan of Care (IPC) and Form 3629, Individual Program Plan Addendum (IPP-A) using a person-centered planning process as described in Section 2300. The SPT should include, at a minimum, the applicant/LAR, case manager and a DSA representative. The individual or LAR may request the SPT include professionals who are qualified by certification or licensure, or training and experience in the habilitation needs of people with related conditions, or directly involved in the delivery of services and supports to the individual. The SPT may include any other people requested by the individual/LAR. The SPT will must make every effort to accommodate these requests by the individual/LAR. Form Resources The following forms may need to be completed as part of the enrollment process: Form 1351, Request to Withdraw from the CLASS Application Process Form 1577, Personal Care Services Selection Form 1581, Consumer Directed Services Option Overview Form 1582, Consumer Directed Services Responsibilities Form 1583, Employee Qualification Requirements Form 1584, Consumer Participation Choice Form 1740, Service Backup Plan Form 2067, Case Information Form 3596, PAS/Habilitation Plan — CLASS/DBMD/CFC Form 3597, CLASS — Habilitation Training Plan Form 3598, Individual Transportation Plan Form 3621, CLASS/CFC — Individual Plan of Care Form 3623, Approval of Application for CLASS Form 3625, CLASS/CFC — Documentation of Services Delivered Form 3628, Provider Agency Model Service Backup Plan Form 3629, Individual Program Plan Addendum Form 3657, Pre-Enrollment Assessment Form 4800-D, DADS Fair Hearing Request Summary Form 8001, Medicaid Estate Recovery Program Receipt Acknowledgement Form 8507, Understanding Program Eligibility - CLASS/DBMD Form 8598, Non-Waiver Services Form 8601, Verification of Freedom of Choice Form 8604, Transition Assistance Services (TAS) Assessment and Authorization Form 8606, Individual Program Plan (IPP) Form H1010, Texas Works Application for Assistance – Your Texas Benefits Form H1200, Application for Assistance – Your Texas Benefits Form H1350, Opportunity to Register to Vote Form H3034, Disability Determination Socio-Economic Report Form H3035, Medical Information Release/Disability Determination Submission Standard — Enrollment The following submission standards apply when submitting enrollment paperwork to DADSHHSC/DADS: Form 1577, Personal Care Services Selection (only applicable to applicants under the age of 21) Choice Lists for the CLASS Program Form 3596, PAS/Habilitation Plan - CLASS/DBMD/CFC Form 3597, CLASS – Habilitation Training Plan (only include if this specific service has been proposed as part of an enrollment IPC) Form 3598, Individual Transportation Plan (only include if this specific service has been proposed as part of an enrollment IPC) Form 3621, CLASS/CFC – Individual Plan of Care Form 3629, Individual Program Plan Addendum Form 3660, Request for Adaptive Aids, Medical Supplies, Minor Home Modifications or Dental Services/Sedation (only include if this specific service has been proposed as part of an enrollment IPC) Form 3849-A, Specifications for Adaptive Aids/Medical Supplies/Minor Home Modifications, including bids (only include if funding for specifications has been proposed as part of an enrollment IPC) Form 6515, CLASS/DBMD Nursing Assessment Form 8578, Intellectual Disability/Related Condition Assessment Form 8598, Non-Waiver Services Form 8601, Verification of Freedom of Choice Form 8604, Transition Assistance Services (TAS) Assessment and Authorization (only include if this specific service has been proposed as part of an enrollment/renewal IPC) Form 8606, Individual Program Plan (IPP) Form 8606-A, Therapy Justifications – Attachment to IPP (only include if this specific service has been proposed as part of an enrollment IPC) Submission Standard — Pre-enrollment The following submission standards apply when submitting paperwork containing funding proposals for pre-enrollment efforts to /HHSDADS: Form 3625, CLASS/CFC – Documentation of Services Delivered; Form 3657, Pre-Enrollment Assessment (partial assessment fee); or Form 3621, CLASS/CFC – Individual Plan of Care (full assessment fee) 2320 Renewal Revision 16-1; Effective January 28, 2016 The case manager must complete the following functions no less than 30 calendar days and no more than 90 calendar days before the end of the current Individual Plan of Care (IPC) year: provide an oral and written explanation to the individual/legally authorized representative (LAR) describing that the Direct Service Agency (DSA) may be requested to provide habilitation CFC PAS/HAB or out-of-home respite in a camp while the individual is temporarily staying outside the catchment area in which the individual resides, but within the state of Texas. The service period cannot exceed 60 consecutive days. The case manager must provide the information contained in 40 Texas Administrative CodeTAC §45.702 regarding this option, including the DSA option to accept or decline the individual’s request; provide information about cognitive rehabilitation therapy (CRT) and assistance for the individual to obtain a neurobehavioral or neuropsychological assessment and plan of care from a qualified professional using Medicaid State Plan, if appropriate; provide Form 8601, Verification of Freedom of Choice, specifying the individual’s choice to continue to receive CLASS services instead of ICF/IID-RC and obtain the individual’s signature; convene a Service Planning Team (SPT) to develop using person-centered planning processes: o a renewal IPC – the CLASS program services on the proposed renewal IPC must meet the following standards: . are necessary to protect the individual's health and welfare in the community; . address the individual's related condition; . are not available to the individual through any other source, including the Medicaid State Plan, other governmental programs, private insurance or the individual's natural supports; . prevent the individual's admission to an institution; . are the most appropriate type and amount of CLASS program services to meet the individual's needs; and . are cost effective; o a renewal Individual Program Plan (IPP) for each service proposed on the renewal IPC; o the Individual Program Plan Addendum; and o a CFC PAS/Habilitation Planhabilitation plan/habilitation training plan; submit by mail to DADSHHSC/DADS the authorized Form 3629, Individual Program Plan Addendum; Form 3621, CLASS/CFC — Individual Plan of Care; Form 8606, Individual Program Plan (IPP); the SPT notes; Form 8606-A, Therapy Justifications — Attachment to IPP, if applicable; Form 3660, Request for Adaptive Aids, Medical Supplies, Minor Home Modifications or Dental Services/Sedation, if applicable; Form 3597, CLASS — Habilitation Training Plan, if applicable; and additional documentation as agreed upon by the SPT for review; and submit a copy of the proposed renewal IPC to the Financial Management Services Agency (FMSA), if applicable. Within ten business days of DADS transmission of the authorized IPC, as evidenced by the fax transmittal date on the documents, the The case manager must provide copies of the authorized Form 3621, Form 8606, Form 3629, the SPT notes, Form 8606-A (if applicable), Form 3660 (if applicable), Form 3597 and additional documentation as agreed upon by the SPT to all members of the SPT. The case manager must provide copies of this documentation to any additional CLASS service providers (FMSA, Continued Family Services [CFS], and Support Family Services [SFS]), as necessary. The case manager must maintain documentation of transmission of all necessary documents. HHSC/DADS will notify the CMA of the IPC authorization through MESAV. Effective January 16, 2017, the CMA will no longer receive the authorized IPC from HHSC/DADS. The CMA must electronically access MESAV to verify that the services on the revision IPC have been authorized by DADS. At DADSHHSC/DADS request, the Case Management Agency (CMA) must submit additional documentation supporting the proposed renewal IPC to DADSHHSC/DADS within 10 business calendar days after DADS requests it. The date of DADSHHSC/DADS request for additional documentation is determined by the date on Form 2067, Case Information, faxed to the CMA that requests the additional documentation. If DADSHHSC/DADS notifies the CMA of the denial or reduction of a CLASS program or CFC service, see Section 2400, Denial, Reduction, Suspension and Termination. Form Resources The following forms may need to be completed as part of the renewal process: Form 1577, Personal Care Services Selection Form 1581, Consumer Directed Services Option Overview Form 1582, Consumer Directed Services Responsibilities Form 1583, Employee Qualification Requirements Form 1584, Consumer Participation Choice Form 1586, Acknowledgement of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) Option Form 1740, Service Backup Plan Form 2067, Case Information Form 3596, PAS/Habilitation Plan — CLASS/DBMD/CFC Form 3597, CLASS — Habilitation Training Plan Form 3598, Individual Transportation Plan Form 3621, CLASS/CFC — Individual Plan of Care Form 3624, Termination, Reduction or Denial of CLASS Form 3625, CLASS/CFC — Documentation of Services Delivered Form 3628, Provider Agency Model Service Backup Plan Form 3629, Individual Program Plan Addendum Form 8578, Intellectual Disability/Related Condition Assessment (Pages 1 and 3) Form 8598, Non-Waiver Services Form 8601, Verification of Freedom of Choice Form 8606, Individual Program Plan (IPP) Form H1350, Opportunity to Register to Vote Choice Lists for the CLASS Program Submission Standard The following submission standards apply when submitting renewal paperwork to DADSHHSC/DADS: Form 1577, Personal Care Services Selection (only applicable to applicants under the age of 21) Choice Lists for the CLASS Program Form 3596, PAS/Habilitation Plan — CLASS/DBMD/CFC Form 3597, CLASS — Habilitation Training Plan (only include if this specific service has been proposed as part of a renewal IPC) Form 3598, Individual Transportation Plan (only include if this specific service has been proposed as part of a renewal IPC) Form 3621, CLASS/CFC — Individual Plan of Care Form 3629, Individual Program Plan Addendum Form 3660, Request for Adaptive Aids, Medical Supplies, Minor Home Modifications or Dental Services/Sedation (only include if this specific service has been proposed as part of a renewal IPC) Form 3849-A, Specifications for Adaptive Aids/Medical Supplies/Minor Home Modifications, including bids (only include Form 3849-A if funding for specifications has been proposed as part of a renewal IPC) Form 6515, CLASS/DBMD Nursing Assessment Form 8578, Intellectual Disability/Related Condition Assessment (ID/RC) Form 8598, Non-Waiver Services Form 8601, Verification of Freedom of Choice Form 8606, Individual Program Plan (IPP) Form 8606-A, Therapy Justifications – Attachment to IPP (only include if this specific service has been proposed as part of a renewal IPC) 2330 Revision Revision 16-1; Effective January 28, 2016 When the case manager is notified of a needed revision to the Individual Plan of Care (IPC), the case manager must ensure: a proposed IPC revision includes an Individual Program Plan (IPP) for each service revised on the proposed IPC, a revised Form 3629, Individual Program Plan Addendum, and a revised PAS/Habilitation Plan - CLASS/DBMD/CFChabilitation plan, if applicable; the CLASS program services on the proposed IPC revision must meet the following standards: o are necessary to protect the individual's health and welfare in the community; o address the individual's related condition; o are not available to the individual through any other source including the Medicaid State Plan, other governmental programs, private insurance, or the individual's natural supports; o prevent the individual's admission to an institution; o are the most appropriate type and amount of CLASS program services to meet the individual's needs; o are cost effective; and the proposed IPC, Individual Program Plan Addendum, IPPs, and PAS/Habilitation Plan - CLASS/DBMD/CFC habilitation plan are submitted to DADSHHSC/DADS for review at least 30 calendar days before the effective date proposed by the Service Planning Team (SPT). At DADS request, the Case Management Agency (CMA) must submit additional documentation supporting the proposed IPC revision to DADS within 10 calendar days after DADS requests it. The date of DADS' request for additional documentation is determined by the date on Form 2067, Case Information, faxed to the CMA that requests the additional documentation. If DADS notifies the CMA of the denial or reduction of a CLASS program or CFC service, see Section 2400, Denial, Reduction, Suspension and Termination. HHSC/DADS will notify the CMA of the IPC authorization through MESAV. Effective January 16, 2017, the CMA will no longer receive the authorized IPC from HHSC/DADS. The CMA must electronically access MESAV to verify that the services on the revision IPC have been authorized by DADS.
Within five business days of DADS transmission of the authorized IPC, as evidenced by the fax transmittal date on the documents, the The case manager must provide copies of Form 3621, CLASS/CFC — Individual Plan of Care; Form 8606, Individual Program Plan (IPP); Form 3629, Individual Program Plan Addendum, the SPT notes; Form 8606-A, Therapy Justifications — Attachment to IPP, if applicable; Form 3660, Request for Adaptive Aids, Medical Supplies, Minor Home Modifications or Dental Services/Sedation, if applicable; Form 3597, CLASS — Habilitation Training Plan, if applicable; and additional documentation as agreed upon by the SPT. The case manager must also provide copies of this documentation within five business days of DADS transmission of the authorized IPC to any additional CLASS service providers (FMSA, CFS, and SFS), as necessary. The case manager must maintain documentation of transmission of all necessary documents. Submission Standard The following submission standards apply when submitting revision paperwork to DADSHHSC/DADS: Form 3596, PAS/Habilitation Plan – CLASS/DBMD/CFC (only include if this specific service has been proposed as part of an IPC revision marked "New" or "Change" in Field 16a on Form 3621) Form 3597, CLASS – Habilitation Training Plan (only include if this specific service has been proposed as part of an IPC revision marked "New" or "Change" in Field 16a on Form 3621) Form 3598, Individual Transportation Plan (only include if this specific service has been proposed as part of an IPC revision marked "New" or "Change" in Field 16a on Form 3621) Form 3621, CLASS/CFC – Individual Plan of Care Form 3629, Individual Program Plan Addendum Form 3660, Request for Adaptive Aids, Medical Supplies, Minor Home Modifications or Dental Services/Sedation (only include if this specific service has been proposed as part of an IPC revision marked "New" or "Change" in Field 16a on Form 3621) Form 3849-A, Specifications for Adaptive Aids/Medical Supplies/Minor Home Modifications, including bids (only include if funding for specifications has been proposed as part of an IPC revision) Form 6515, CLASS/DBMD Nursing Assessment Form 8598, Non-Waiver Services Form 8606, Individual Program Plan (IPP) (only include if this specific service has been proposed as part of an IPC revision marked "New" or "Change" in Field 16a on Form 3621) Form 8606-A, Therapy Justifications – Attachment to IPP (only include if this specific service has been proposed as part of an IPC revision marked "New" or "Change" in Field 16a on Form 3621) 2331 Immediate Jeopardy of CLASS Individual Revision 15-2; Effective November 20, 2015 When the Case Management Agency (CMA) receives written documentation from the Direct Service Agency (DSA) indicating the DSA provided habilitationCFC PAS/HAB, respite, nursing, dental services or an adaptive aid that is not included on the individual's Individual Plan of Care (IPC) in response to a situation of the individual's immediate jeopardy, the case manager must complete and submit a proposed IPC revision, revised Individual Program Plan Addendum, revised Individual Program Plans (IPPs) and documentation to DADSHHSC/DADS within seven calendar days of notification by the DSA. The CMA must use the date which the DSA RN documented determination the individual was subject to immediate jeopardy without the provision of additional habilitationCFC PAS/HAB, respite, nursing, dental services, or an adaptive aid that is not included on the individual's IPC as the IPC revision effective date. The documentation furnished to the CMA by the DSA must include: a description of circumstances necessitating the provision of the new service or the increase in the amount of the existing service; and documentation by a registered nurse of the nurse's determination the service was necessary to prevent the individual's health and safety from being placed in immediate jeopardy. DADSHHSC/DADS authorizes the IPC only if, after reviewing the documentation, DADSHHSC/DADS determines the service was necessary to prevent the individual's health and safety from being placed in immediate jeopardy. At DADSHHSC/DADS request, the CMA must submit additional documentation supporting the proposed IPC revision to DADSHHSC/DADS within 10 calendar days. HHSC/DADS will notify the CMA of the IPC authorization through MESAV. Form Resources The following forms may need to be completed as part of the revision process: Form 1740, Service Backup Plan Form 2067, Case Information Form 3621, CLASS/CFC – Individual Plan of Care Form 3596, PAS/Habilitation Plan - CLASS/DBMD/CFC Form 3597, CLASS – Habilitation Training Plan Form 3598, Individual Transportation Plan Form 3628, Provider Agency Model Service Backup Plan Form 3629, Individual Program Plan Addendum Form 8606, Individual Program Plan (IPP) 2340 Transfer Revision 13-2; Effective September 6, 2013 When the individual/legally authorized representative (LAR) notifies the case manager they wish to be transferred to a different agency(s), the case manager must: document in the individual's Individual Program Plan Addendumrecord the date the transfer request was received; provide the individual/LAR with the most current selection determination document for the applicable catchment area; make transfer arrangements with the individual/LAR, the receiving Case Management Agency (CMA), Direct Service Agency (DSA) or Financial Management Services Agency (FMSA), as appropriate; establish an effective date for the individual's transfer that is at least 14 calendar days after the date of receiving notice of intent to transfer; and coordinate with the agencies involved in the transfer to determine the number of needed service units for each authorized service code. The current CMA must submit the following to DADSHHSC/DADS before the effective date of the transfer: the individual's currently authorized Individual Plan of Care (IPC) the individual’s Individual Program Plan Addendum Form 3621-T, CLASS/CFC – IPC Service Delivery Transfer Worksheet Choice Lists for the CLASS Program HHSC/DADS will notify the CMA of the IPC authorization through MESAV. Form Resources The following forms may need to be completed as part of the transfer process: Form 2067, Case Information Form 3621-T, CLASS/CFC – IPC Service Delivery Transfer Worksheet Form 3629, Individual Program Plan Addendum Choice Lists for the CLASS Program Submission Standard The following submission standards apply when submitting transfer paperwork to DADSHHSC/DADS: Form 3621-T, CLASS/CFC – IPC Service Delivery Transfer Worksheet Form 3629, Individual Program Plan Addendum Choice Lists for the CLASS Program 2350 IPP Service Review Revision 15-2; Effective November 20, 2015 The case manager is responsible for ongoing monitoring of: the provision of CLASS program and CFC services; and the status of non-CLASS program services and supports. The case manager must meet with the individual or legally authorized representative (LAR) in the individual's home, or other location if services are not primarily provided in the individual’s home, to review the Individual Plan of Care (IPC) and update the Individual Program Plan Addendum, if needed. at least every three months, from the effective date of the most recent enrollment or renewal IPC and as needed during the IPC year. CMA Individual Program Plan (IPP) service reviews will occur in accordance with the schedule in Appendix X, IPP Service Summary/IPP Service ReviewQuarterly Due Dates Chart, from the effective date of the most recent enrollment or renewal IPC. The fourth quarterly review of the IPC year is combined with the meeting of the Service Planning Team (SPT) to develop a renewal IPC. The Individual Program Plan AddendumSPT notes will document the development of the renewal IPC using person-centered planning processes. The case manager must use Form 3595, IPP Service Review, to document the review of the services delivered to the individual since the ninth month IPP Service Reviewquarterly review. The purpose of meeting the individual or LAR in the setting where services are delivered is to allow the case manager to verify that services listed on the IPC are delivered as described in the Individual Program Plan (IPP). This function is best accomplished by the case manager observing CLASS services in the setting in which they are provided. Since most individuals receive CLASS services in the home setting, the quarterly service reviews should occur in the location where the majority of services are delivered. While individuals or their LAR may request the case manager meet in locations other than their own home/family home, case managers should remind them that a complete assessment of services provided to the individual is required to be performed in the setting in which those services are delivered. Case managers must document when and why an individual or LAR refuses to meet in the home setting in the “General Comments” section of Form 3595. During the quarterly IPP service review face-to-face contact with the individual, the case manager must complete Form 3595 to: review the services received as documented on the IPC; document progress or lack of progress toward goals/objectives as identified on the IPP/IPC; assess the individual's satisfaction with the provision of CLASS program services; determine if the service backup plan was implemented and if it met the needs of the individual; and identify any changes to the individual's needs to include any needed revisions to the service backup plan. The case manager is required to complete all sections of Form 3595 for CLASS services provided to an individual. The case manager may choose to print only those pages that reflect the services reviewed and provide them to the individual, the direct service agency (DSA) and any additional CLASS service providers (FMSA, CFS, and SFS), as necessary. If an individual's IPC includes any nursing services or CFC PAS/HAB, and any of those services are not currently identified as requiring a service backup plan, the case manager must discuss with the individual or LAR whether any of those services may now be critical to the individual's health and safety. If the case manager and individual/LAR determines a either service may now be critical to the individual's health and safety, the case manager must convene the SPT to discuss development of a service backup plan. The case manager must also ask the individual/LAR if a service backup plan was implemented during the most recent review period and discuss the implementation of the service backup plan with the individual/LAR to determine whether or not the plan was effective. If the service backup plan was implemented and determined to be ineffective, the case manager must convene an SPT meeting to revise the service backup plan. If a change is requested by the individual during the quarterly service review, the case manager is responsible for initiating any change(s) needed and convenes the SPT, as applicable, ; within five business days after becoming aware that the individual's needs have changed The case manager must also update the Individual Program Plan Addendum. Within five business days of the quarterly service review, the case manager is responsible for providing copies of the service review with the updated Individual Program Plan Addendum to the individual, DSA and any additional CLASS service providers (FMSA, CFS, and SFS), as necessary. The case manager must maintain documentation of transmission of all necessary documents. Form Resources The following forms may need to be completed as part of the 90-day service review: Form 2067, Case Information Form 3595, IPP Service Review Form 3621, CLASS/CFC – Individual Plan of Care 2400 Denial, Reduction, Suspension and Termination Revision 13-2; Effective September 6, 2013 An individual whose CLASS program or CFC services are denied, reduced, suspended or terminated must be given notice of adverse actions taken by DADSHHSC/DADS and is entitled to a fair hearing. The CMA must obtain written authorization from DADSHHSC/DADS for all suspensions of CLASS program or CFC services. DADSHHSC/DADS issues a notice to the CMA of all denials of enrollment or terminations from the CLASS program. The CMA must notify the individual, DSA, FMSA, CFS and SFS provider as applicable. Program services may be terminated if the individual does not comply with the conditions as outlined in 40 TAC §45.406 or violates any of the conditions specified in 40 TAC §45.408. Program services may also be terminated if an individual does not comply with 40 TAC §45.407, or exhibits behavior that places the health and safety of the CMA's case manager or a DSA's service provider in immediate jeopardy as described in 40 TAC §45.409. 2410 Denial Revision 13-2; Effective September 6, 2013 Denial is a DADSHHSC/DADS action that disallows: an individual's request for enrollment in the CLASS program; a service requested on the IPC that was not authorized on the prior IPC; or a portion of the amount or level of the service requested on the IPC that was not authorized on the prior IPC. Denial of a Request for Enrollment into the CLASS Program DADSHHSC/DADS denies an individual's request for enrollment into the CLASS program if: the individual does not meet the eligibility criteria described in §45.201, Eligibility Criteria; or the DSAs serving the catchment area in which the individual resides are not willing to provide CLASS program services to the individual because they have determined that they cannot ensure the individual's health and safety. If DADSHHSC/DADS denies a request for enrollment, DADSHHSC/DADS sends written notice to the individual or LAR of the denial of the individual's request for enrollment into the CLASS program and includes in the notice the individual's right to request a fair hearing in accordance with 40 TAC§45.301, Individual's Right to a Fair Hearing. DADS sends a copy of the written notice to the individual's DSA, CMA and, if selected, FMSA. Denial of a CLASS Program Service DADSHHSC/DADS denies a CLASS program service on an individual's IPC if services: are not necessary to protect the individual's health and welfare in the community; do not address the individual's related condition; are available to the individual through any other source including the Medicaid State Plan, other governmental programs, private insurance or the individual's natural supports; do not prevent the individual's admission to an institution; are not the most appropriate type and amount of CLASS program and CFC services to meet the individual's needs; or are not cost effective. If DADSHHSC/DADS denies a CLASS program or CFC service on an individual's IPC, DADSHHSC/DADS notifies the CMA in writing. Upon receipt of DADSHHSC/DADS written notice of denial of a CLASS program or CFC service, the CMA must send Form 3624, Termination, Reduction or Denial of CLASS, to the individual/LAR of the denial of the service, copying the individual's DSA and, if selected, FMSA, CFS or SFS provider. Form Resources The following forms may need to be completed as part of a suspension denial of services: Form 2067, Case Information Form 3624, Termination, Reduction or Denial of CLASS Form 4800-D, DADS Fair Hearing Request Summary Submission Standard The following submission standards apply when submitting a request for an appeal to DADSHHSC/DADS: Form 3624, Termination, Reduction or Denial of CLASS Written documentation established by the CMA in the event of a verbal request for appeal by individual/LAR (only if individual/LAR did not exercise their appeal rights using Form 3624) Form 4800-D, Fair Hearing Request Summary Form 4800-DA, 4800-D Addendum (only if there are more than three other hearing participants who require notification of a hearing) 2420 Reduction Revision 15-2; Effective November 20, 2015 Reduction is a DADSHHSC/DADS action taken as a result of a review of an Individual Plan of Care (IPC) that decreases the amount or level of a service authorized by DADSHHSC/DADS on an prior IPC. DADSHHSC/DADS will perform utilization review on all IPCs that meet criteria outlined in Section 5000, Utilization Review (UR). All services and units of service included on a proposed IPC must be justified by the Service Planning Team (SPT). DADSHHSC/DADS CLASS Program staff review the IPC to ensure the services on the IPC: are necessary to protect the individual's health and welfare in the community; supplement rather than replace the individual's natural supports and other non-CLASS program services and supports for which the individual may be eligible; prevent the individual's admission to an institution; are the most appropriate type and amount of services to meet the individual's needs; and are cost effective. The case manager has the responsibility to gather the following information for the DADSHHSC/DADS CLASS program staff: assessments, reports, professional observations, or other resources. The case manager must summarize this information using the appropriate Individual Program Plan (IPP). As necessary during the review of a proposed IPC, DADSHHSC/DADS CLASS program staff will ask case managers to provide additional justification if the initial information submitted with a proposed IPC is not sufficient to demonstrate the need for requested services or does not meet requirements for a CLASS IPC as outlined in Section 1000, Introduction. If information submitted to DADSHHSC/DADS by the case manager does not provide sufficient information to justify requested units of services, DADSHHSC/DADS will modify the IPC by reducing the number of units of services as necessary and will notify send the Case Management Agency (CMA) a copy of the modified IPC.of the reduction in writing. If an individual's services are reduced, the CMA must notify the individual and provide a copy of the notification to the Direct Service Agency (DSA), Financial Management Services AgencyFMSA and Support Family Services provider, as applicable, of the documentation of the reason for the reduction. Upon receipt of a written notice proposing to reduce a service, the CMA must inform the individual or legally authorized representative (LAR) of DADSHHSC/DADS decision. The CMA informs the individual of the right to request a fair hearing. The case manager sends written notice on Form 3624, Termination, Reduction or Denial of CLASS, to the individual allowing 12 days for the participant individual to respond before taking any action to reduce services. If the individual or LAR requests a fair hearing before the effective date of the reduction of a CLASS program service, as specified in the written notice, the DSA must provide the service to the individual in the amount authorized in the prior IPC while the appeal is pending. Form Resources The following forms may need to be completed as part of a suspension reduction of services: Form 2067, Case Information Form 3624, Termination, Reduction or Denial of CLASS Form 4800-D, Fair Hearing Request Summary Submission Standard The following submission standards apply when submitting a request for an appeal to DADSHHSC/DADS: Form 3624, Termination, Reduction or Denial of CLASS Written documentation established by the CMA in the event of a verbal request for appeal by individual/LAR (only if individual/LAR did not exercise their appeal rights using Form 3624) Form 4800-D, Fair Hearing Request Summary Form 4800-DA, 4800-D Addendum (only if there are more than three other hearing participants who require notification of a hearing) 2430 Suspension Revision 15-2; Effective November 20, 2015 Individuals may not receive CLASS program or CFC services during a period of time in which they are admitted to a facility listed in this section. Individuals must be suspended without prior notification from CLASS program or CFC services until such time as the individual returns to his own or family home or is terminated from the CLASS program. The individual is not eligible for continuation of CLASS program or CFC services until the fair hearing process is completed because suspension of an individual's services is effective the date the individual was temporarily admitted to one of the facilities listed below, or leaves the state and, therefore, the individual is not given advance notice of the suspension. Within two business days after the Case Management Agency (CMA) becomes aware of a situation that necessitates an individual's CLASS program or CFC services to be suspended, the CMA must send a written request for suspension with written supporting documentation to DADSHHSC/DADS CLASS program staff. DADSHHSC/DADS notifies the individual's CMA in writing of whether it authorizes a suspension of CLASS program or CFC services. Suspension is a DADSHHSC/DADS action taken: upon an individual's admission for any length of time up to 180 consecutive calendar days to one of the following facilities: o an ICF/IID licensed or subject to being licensed in accordance with Texas Health and Safety Code, Chapter 252, or certified by DADSHHSC/DADS, unless the individual is receiving out-of-home respite in the facility; o a nursing facility licensed or subject to being licensed in accordance with Texas Health and Safety Code, Chapter 242, unless the individual is receiving out-of- home respite in the facility; o an assisted living facility licensed or subject to being licensed in accordance with Texas Health and Safety Code, Chapter 247; o a residential child-care operation licensed or subject to being licensed by the Department of Family and Protective Services (DFPS), unless it is a foster family home or a foster group home; o a facility licensed or subject to being licensed by the Department of State Health Services (DSHS); o a facility operated by the Department of Assistive and Rehabilitative Services (DARS); or o a residential facility operated by the Texas Youth Commission, a jail or prison; or upon an individual leaving the state for up to 180 consecutive calendar days, except when individuals receiving certain services available through the CDS option while the individual is temporarily staying at a location outside the State of Texas. For more details, see Information Letter No. 16-35, Receiving Services Outside the State of Texas in the CLASS and DBMD Programs. Upon receipt of a written notice from DADSHHSC/DADS authorizing the suspension of CLASS program or CFC services, the CMA must send the written notice of suspension to the individual/legally authorized representative (LAR), Direct Service Agency DSA and Financial Management Services AgencyFMSA, if applicable. The written notice includes the individual's right to request a fair hearing. The period of suspension is the length of the admission to the facility or the time spent in another state. An individual may remain on suspension from CLASS program or CFC services for up to 180 calendar days. DADSHHSC/DADS may extend an individual's suspension for 30 calendar days upon the CMA's request. Form Resources The following forms may need to be completed as part of a suspension of services: Form 2067, Case Information Form 3624, Termination, Reduction or Denial of CLASS Form 4800-D, Fair Hearing Request Summary Submission Standard The following submission standards apply when submitting a request for an appeal to DADSHHSC/DADS: Form 3624, Termination, Reduction or Denial of CLASS Written documentation established by the CMA in the event of a verbal request for appeal by individual/LAR (only if individual/LAR did not exercise their appeal rights using Form 3624) Form 4800-D, Fair Hearing Request Summary Form 4800-DA, 4800-D Addendum (only if there are more than three other hearing participants who require notification of a hearing) 2440 Termination Revision 11-1; Effective June 13, 2011 Termination is a DADSHHSC/DADS action that results in the loss of the individual's authorized services in the CLASS program and CFC. 2441 Termination With Advanced Notice Revision 13-2; Effective September 6, 2013 DADSHHSC/DADS terminates an individual's CLASS program and CFC services if: the individual does not meet program eligibility criteria; the individual is admitted for more than 180 consecutive calendar days to one of the following facilities: o an ICF/IID licensed or subject to being licensed in accordance with Texas Health and Safety Code, Chapter 252 or certified by DADSHHSC/DADS, unless the individual is receiving out-of-home respite in the facility; o a nursing facility licensed or subject to being licensed in accordance with Texas Health and Safety Code, Chapter 242, unless the individual is receiving out-of- home respite in the facility; o an assisted living facility licensed or subject to being licensed in accordance with Texas Health and Safety Code, Chapter 247; o a residential child-care operation licensed or subject to being licensed by the Department of Family and Protective Services (DFPS), unless it is a foster family home or a foster group home; o a facility licensed or subject to being licensed by the Department of State Health Services (DSHS); o a facility operated by the Department of Assistive and Rehabilitative Services (DARS); o a residential facility operated by the Texas Juvenile Justice Department, a jail or prison; or the individual leaves the state for more than 180 consecutive calendar days and DADSHHSC/DADS has not extended the individual's suspension; Direct Service Agencies (DSAs) serving the catchment area in which the individual resides are not willing to provide CLASS program and CFC services to the individual because they have determined that they cannot ensure the individual's health and safety; or the individual refuses to comply with a mandatory participation requirement as follows: o not completing and submitting an application for Medicaid financial eligibility to the Health and Human Services Commission (HHSC) within 30 calendar days after the case manager's initial face-to-face, in-home visit (Note: If an individual or legally authorized representative (LAR) does not submit a Medicaid application to HHSC within 30 calendar days of the case manager's initial face-to- face, in-home visit as required but is making good faith efforts to complete the application, the Case Management Agency (CMA) may extend this time frame in 30 calendar-day increments as approved by DADSHHSC/DADS CLASS program staff.); o not participating with the Service Planning Team (SPT) to: . develop an enrollment Individual Plan of Care (IPC); . develop, renew, or revise an Individual Program Plan Addendum; . renew and revise the IPC and Individual Program Plans (IPPs); o not reviewing, agreeing to, signing and dating an IPC, Individual Program Plan Addendum, and IPPs; o not using natural supports and other non-CLASS program or CFC services and supports for which the individual may be eligible before using CLASS program services; o not cooperating with the CMA and DSA in the delivery of CLASS program and CFC services listed on the individual's IPC, including: . working with the CMA and DSA in scheduling meetings; . attending scheduled meetings with the case manager or service provider; . being available to receive the CLASS program or CFC services; . notifying the CMA or DSA in advance if the individual or LAR is unable to attend a scheduled meeting or is unavailable to receive services in the individual's own or family home; . admitting CMA and DSA representatives to the individual's own home or family home for a scheduled meeting or to receive CLASS program and CFC services; o not cooperating with the DSA's CLASS program or CFC service providers to ensure progress toward achieving the goals and objectives described in the IPP for each CLASS program or CFC service listed on the IPC; o not paying a required copayment in a timely manner when found by HHSC to be financially eligible for CLASS program and CFC services based on the special institutional income limit; o not completing the procedures for redetermining eligibility for Medicaid, as described in the Medicaid for the Elderly and People with Disabilities Handbook; o engaging in criminal behavior in the presence of the case manager or CLASS program or CFC service provider; o permitting a person present in the individual's own or family home to engage in criminal behavior in the presence of the service provider or case manager; o acting in a manner that is threatening to the health and safety of the case manager or CLASS program or CFC service provider; o permitting a person present in the individual's own or family home to act in a manner that is threatening to the health and safety of the case manager or CLASS program or CFC service provider; o exhibiting behavior or permitting a person present in the individual's residence to exhibit behavior that places the health and safety of the case manager or CLASS program or CFC service provider in immediate jeopardy; o initiating or participating in fraudulent health care practices; o engaging in behavior that endangers the individual's health or safety; and o permitting a person present in the individual's own home or family home to engage in behavior that endangers the individual's health or safety. Within two business days after the CMA becomes aware of one of the situations described above, the CMA must send a written request of proposed CLASS termination of CLASS program and CFC services to DADSHHSC/DADS. The request must be accompanied by documentation supporting the proposed termination. If termination of services is requested based on a determination by the DSA that it cannot ensure the individual's health and safety, the CMA must include in the request specific reason(s) why the DSA determines it cannot ensure the individual's health and safety. Prior to termination of services, an individual may choose another DSA. The CMA must provide the most current Selection Determination document in catchment areas with multiple DSAs. If another DSA determines the individual’s medical and nursing needs can be adequately met, the CMA must initiate a transfer IPC as described in Section 2340 of the CLASS Provider Manual. DADSHHSC/DADS notifies the individual's CMA in writing using Form 3624, Termination, Reduction or Denial of CLASS, or written notice from DADSHHSC/DADS, of whether it authorizes the proposed termination of CLASS program and CFC services. Upon receipt of DADSHHSC/DADS notification authorizing a proposed termination of CLASS program services, the CMA must send written notice of the termination of CLASS program and CFC services to the individual or LAR within two business days. The CMA must send a copy of the termination notice to the individual's DSA and, if selected, Financial Management Services Agency (FMSA), CFS and Support Family Service Agency (SFS) provider. The CMA must include in the notice the individual's right to request a fair hearing. In the event CLASS program services are terminated due to an individual's IPC cost being over $114,736.07, DADSHHSC/DADS sends written notice to the individual or LAR of the proposal to terminate CLASS program services and includes the individual's right to request a fair hearing in the notice. DADSHHSC/DADS sends a copy of the written notice to the individual's DSA, CMA, and if selected, FMSA. If a CMA becomes aware an individual has not complied with a mandatory participation requirement described in this section, the CMA must immediately attempt to resolve the situation, including facilitating at least one face-to-face meeting with the SPT. If, after making attempts to resolve the situation, the CMA determines that the situation cannot be resolved, the CMA must request in writing that DADSHHSC/DADS terminate CLASS program services for the individual. The request must be sent to DADSHHSC/DADS within two business days of the CMA's determination the situation cannot be resolved and be supported by written documentation. The written documentation must include a description of: the situation that resulted in the request to terminate CLASS program and CFC services; and the attempts by the CMA and DSA to resolve the situation, including face-to-face meetings with the individual or LAR. If an individual's CLASS Program services and CFC services are terminated, the CMA must ensure that the case manager informs the individual of alternative long-term care services and supports in the community. The explanation must include advising the individual about receiving CFC services through a managed care organization and institutional services, such as an Intermediate Care Facilities for Individuals with an Intellectual Disability or Related Conditions (ICF/IID). More information can be located on the Texas Health and Human Services website. The CMA will not provide notice of a termination of CLASS program and CFC services to an individual for whom DADSHHSC/DADS has terminated due to an IPC cost being over $114,736.07. DADSHHSC/DADS will provide notice to individuals in this situation directly. If the individual or LAR requests a fair hearing before the effective date of a proposed termination of CLASS program services, the DSA must provide services to the individual in the amounts authorized in the IPC while the appeal is pending. 2442 Termination Without Advanced Notice Revision 13-2; Effective September 6, 2013 DADSHHSC/DADS terminates an individual's CLASS program services without advanced notice if any of the following situations exist: the CMA or DSA has factual information confirming the death of the individual; the CMA or DSA receives a clearly written statement signed by the individual that the individual no longer wishes to receive CLASS program services; the individual's whereabouts are unknown and the post office returns mail directed to him or her by the CMA or DSA, indicating no forwarding address; the CMA or DSA establishes the individual has been accepted for Medicaid services by another state; or an individual or a person in the individual's residence exhibits behavior that places the health and safety of the CMA's case manager or a DSA's service provider in immediate jeopardy. See Section 2443, Immediate Jeopardy of CLASS Providers. Within two business days after the CMA becomes aware of a situation such as described above, the CMA must send a written request to terminate CLASS program and CFC services to DADSHHSC/DADS. The written request must be accompanied by documentation supporting the request. If an individual's CLASS Program services and CFC services are terminated, the case manager must document attempts to inform the individual of alternative long-term care services and supports in the community. The explanation must include advising the individual about receiving CFC services through a managed care organization and institutional services, such as an Intermediate Care Facilities for Individuals with an Intellectual Disability or Related Conditions (ICF/IID). More information can be located on the Texas Health and Human Services website. DADSHHSC/DADS notifies the individual's CMA in writing of whether it authorizes the termination of CLASS program services. Upon receipt of a written notice from DADSHHSC/DADS authorizing the termination of CLASS program services, the CMA must send written notice to the individual or LAR of the termination. The CMA must also send a hard copy of the termination notice to the individual's DSA and, if selected, FMSA, CFS, and SFS provider. The CMA must include in the notice the individual's right to request a fair hearing. 2443 Immediate Jeopardy of CLASS Providers Revision 13-2; Effective September 6, 2013 DADSHHSC/DADS may terminate an individual's CLASS program services if an individual or a person in the individual's residence exhibits behavior that places the health and safety of the CMA's case manager or a DSA's service provider in immediate jeopardy. If a CMA or DSA becomes aware a situation exists that places the health and safety of the individual's case manager, or DSACLASS program or CFC service provider in immediate jeopardy, the CMA or DSA must: immediately file a report with the appropriate law enforcement agency and, if appropriate, make an immediate referral to DFPS; and notify DADSHHSC/DADS, CMA and DSA by telephone of the situation no later than one business day after the CMA or DSA becomes aware of the situation. The CMA and DSA must attempt to resolve the situation. If, after making attempts to resolve the situation, the CMA determines that the situation cannot be resolved, the CMA must, within two business days after the CMA becomes aware of the situation, send a written request to terminate CLASS program and CFC services to DADSHHSC/DADS. The written request must be accompanied by: a description of the situation that resulted in the request to terminate the individual's CLASS program and CFC services; a detailed description of the attempts by the CMA to resolve the situation; and if available, a copy of any report issued by a law enforcement agency or DFPS regarding the situation. DADSHHSC/DADS notifies the individual's CMA in writing of whether it authorizes the proposed termination of CLASS program services. Upon receipt of written notice from DADSHHSC/DADS authorizing the termination of CLASS program services, the CMA must, no later than the date of the termination of services, send written notice to the individual or LAR of such termination. The CMA must provide a hard copy of the termination notice to the individual's DSA and, if selected, FMSA, CFS, and SFS provider. The CMA must include in the notice the individual's right to request a fair hearing. If an individual's CLASS Program services and CFC services are terminated, the case manager must document attempts to inform the individual of alternative long-term care services and supports in the community. The explanation must include advising the individual about receiving CFC services through a managed care organization and institutional services, such as an Intermediate Care Facilities for Individuals with an Intellectual Disability or Related Conditions (ICF/IID). More information can be located on the Texas Health and Human Services website. The CMA and DSA must maintain documentation of completion of these requirements in the individual's record. Form Resources The following forms may need to be completed as part of termination of services: Form 2067, Case Information Form 3624, Termination, Reduction or Denial of CLASS Form 3629, Individual Program Plan Addendum Form 4800-D, Fair Hearing Request Summary Submission Standard — Termination The following submission standards apply when submitting termination paperwork to DADSHHSC/DADS: Form 3621, CLASS/CFC – Individual Plan of Care Form 3624, Termination, Reduction or Denial of CLASS Form 3629, Individual Program Plan Addendum Documentation of circumstances that support the termination of CLASS services. Submission Standard — Appeal The following submission standards apply when submitting a request for an appeal to DADSHHSC/DADS: Form 3624, Termination, Reduction or Denial of CLASS Written documentation established by the CMA in the event of a verbal request for appeal by individual/LAR (only if individual/LAR did not exercise their appeal rights using Form 3624) Form 3629, Individual Program Plan Addendum Form 4800-D, Fair Hearing Request Summary Form 4800-DA, 4800-D Addendum (only if there are more than three other hearing participants who require notification of a hearing) 2500 Provision of Direct Services by CMA Revision XX-X; Effective A CLASS CMA is only authorized to provide case management services to individuals served by the CMA. Title 42 of the Code of Federal Regulations (CFR) in 42 CFR §441.301(c)(1)(vi) specifies providers of home and community-based services for the individual, or those who have an interest in or are employed by a provider of home and community-based services for the individual must not provide case management or develop the person-centered service plan. After reviewing the CLASS waiver application, HHSC has determined the Centers for Medicare and Medicaid Services (CMS) intends to maintain CMA services and DSA services separate. CMS has had concerns in other Texas 1915(c) waivers regarding conflict of interest.
Therefore, a CMA or any other division of the agency must not provide any other services to an individual receiving case management services from the CMA. This interpretation is consistent with CLASS rules in Texas Administrative Code, specifically 40 TAC §45.703(b)(3) that states a case manager is not employed by or contracting with a DSA to provide a direct service to an individual served by the CMA.