1110 Legal Base

Revision 25-3; Effective June 1, 2025

Community Care Services Eligibility (CCSE) is a group of services purchased by the Texas Health and Human Services Commission (HHSC) in response to Texas Legislature recommendations. CCSE provides services in a person's home or community for Texans who are not self-sufficient, and who might otherwise be subject to premature institutionalization or to abuse, neglect or exploitation (ANE). CCSE includes the following direct services for eligible people. Detailed descriptions of the services are in 4000, Specific CCSE Services:

• Adult Foster Care (AFC) — 24-hour care in a family home or small group home.
• Day Activity and Health Services (DAHS) — up to 10 hours of care per day in a licensed facility, supervised by a licensed nurse.
• Emergency Response Services (ERS) — an electronic signaling device for emergencies.
• Meals Services — Home-Delivered Meals (HDM).
• Personal Attendant Services (PAS) — help with personal care and housekeeping tasks:
  • Community Attendant Services (CAS) — provides in-home attendant services to people with an approved medical need for help with personal care tasks. CAS Services are provided under Title XIX of the Social Security Act.
  • Family Care (FC) — provides in-home attendant services to eligible adults. FC serves people who may or may not need personal care.  FC services are provided under Title XX of the Social Security Act.
• Primary Home Care (PHC) — provides in-home attendant services to people who receive Medicaid and have an approved medical need for help with personal care tasks.  PHC services are provided under Title XIX of the Social Security Act.
• Residential Care — 24-hour care in a group setting, including:
  • Emergency Care (EC) — care given to people who need immediate shelter or 24-hour care; or
  • Residential Care (RC) — 24-hour care in licensed assisted living facilities.
• Special Services to Persons with Disabilities (SSPD) — a variety of in-home care and advocacy services for people who live with disabilities.

HHSC also provides CCSE case management information and referral (I&R) to other service resources. Case management is direct assistance to eligible people to manage mutually planned services and that use the person’s own resources as well as community resources. These services are planned to enable people to carry out activities of daily living and to continue living in the community. Review 2000, Case Management and Appendix XXIV, Legal Basis for Community Care Programs.

1120 Program Goals

Revision 25-3; Effective June 1, 2025

CCSE goals are:

• to enable older people and people with disabilities to achieve or maintain personal self-sufficiency, to help them reduce or prevent dependency, and to help them accept and understand dependency when it occurs because of illness, accident or typical aging;
• to prevent or reduce unnecessary institutional care by providing home-based and other less intensive care and to help people access institutional services when necessary and appropriate; and
• to prevent abuse, neglect, or exploitation (ANE), including adult self-neglect, and to refer to Adult Protective Services (APS), adults who appear to be victims of abuse, neglect, or exploitation by others.

1130 Definitions

Revision 25-3; Effective June 1, 2025

Definitions used in the CCSE handbook mean the following unless the handbook shows otherwise:

Abuse –

• the negligent or willful infliction of injury, unreasonable confinement, intimidation, or cruel punishment with resulting physical or emotional harm or pain to an older adult or person with a disability by the person's caretaker, family member, or other individual who has an ongoing relationship with the person; or
• any involuntary or nonconsensual sexual conduct that would constitute an offense under section 21.08, Penal Code (indecent exposure) or Chapter 22, Penal Code (assaultive offenses), committed by the person's caretaker, family member, or other individual who has an ongoing relationship with the person.

Activities of daily living - Activities essential to self-care and daily tasks, including bathing, eating, dressing, grooming, walking, toileting, housekeeping, shopping and meal preparation.

Adult - A person 18 or older or an emancipated minor.

Adult Foster Care (AFC) - Services provided in a 24-hour living arrangement in an adult foster care home for people who cannot continue to function independently in their own homes because of physical, mental or emotional limitations.

Aged or older adult - A person 65 or older.

Applicant - A person applying for CCSE services.

Attendant - A person whom a provider agency employs to provide personal care, housekeeping, or both to people eligible to receive Personal Attendant Services (PAS) according to a service plan.

Caregiver - A relative, guardian, representative payee, or a person with frequent or regularly scheduled contact with the applicant or recipient. A personal relationship exists, or the applicant or recipient perceives that person as having a role in helping them meet their basic needs.

Caregiver support - Relief or rest from caregiving duties given to or arranged for an applicant or recipient’s caregiver.

Caseworker - A CCSE employee responsible for determining eligibility and case management activities.

Categorial Eligibility - Review 2341.3, Categorical Eligibility for a complete description.

Client - A person receiving CCSE services. The person may also be referred to as a recipient.

Community Attendant Services (CAS) - A non-technical, medically related personal care service available to eligible people whose health problems limit them from performing activities of daily living per a practitioner’s statement of medical need.

Community care services - Services provided within a person’s home or community as alternatives to institutional care.

Community Care Interest List - A list containing the names of people interested in receiving a community care service or program when funds are unavailable.

Community Care Services or Programs -

• Adult Foster Care
• Community Attendant Services (CAS)
• Consumer Managed Personal Attendant Services (CMPAS)
• Day Activity Health Services (DAHS)
• Emergency Response Services (ERS)
• Family Care (FC)
• Home Delivered Meals (HDM)
• Primary Home Care (PHC)
• Residential Care (RC)
• Special Services to Persons with Disabilities (SSPD)

Consumer Managed Personal Attendant Services (CMPAS) - An HHSC program for personal attendant services where recipients manage their attendant services to varying degrees. Attendant services help the recipient function independently in the community. Recipients interview, select, train, supervise, and release their attendants. Services include:

• Attendant care provided as needed by attendants selected by the recipient.
• Health-related tasks prescribed by a medical practitioner.

Day Activity and Health Services (DAHS) - Services designed to meet an adult’s needs in a Texas HHS-licensed Day Activity and Health Services facility.

Disabled - Review Person with Disabilities

Earned income - Cash or liquid resources an applicant or recipient receives for services performed as an employee or because of self-employment.

Emancipated minor - A person under 18 with the power and capacity of an adult. This includes a minor who has had the definition of minority removed by a court of law or who has been married, with or without parental consent.

Emergency Response Services (ERS) - An electronic monitoring service for adults with functional impairments. Review 4312.1, Eligibility.

Expedited response - An initial visit, either by phone or in-person, for services of an applicant by the caseworker within five calendar days from the date of assignment. Review 2320, Caseworker Response.

Exploitation - The illegal or improper act or process of a caregiver, family member, or other person with an ongoing relationship to an older adult or person with a disability. It involves using, or attempting to use, the resources of the older adult or person, including the person’s social security number or other identifying information, for monetary or personal benefit, profit or gain. It is done without the informed consent of the person.

Facility - A place that delivers daily or 24-hour residential services to people.

Family Care (FC) - A program authorized under Title XX of the Social Security Act that provides personal attendant services to eligible people.

Fraud - The deliberate misrepresentation or intentional concealment of information to receive or be reimbursed for the delivery of services to which a person is not entitled.

Functional need - A person’s requirement for help with activities of daily living caused by a physical limitation, medical condition or disability.

HHSC region - One of eleven regions of Texas that provide access to and support for HHSC services.

Home-Delivered Meals (HDM) - This program, funded by Title XX of the Social Security Act and administered by HHSC, involves a provider agency delivering meals to eligible people.

Immediate response - An initial visit, either by phone or in-person, for services of an applicant by the caseworker within 24 hours from the date of assignment. Review 2320, Caseworker Response, for detailed information.

Income eligible - An adult who is not categorically eligible but has income and resources equal to or less than the eligibility level established by HHSC.

Institution - A nursing home, intermediate care facility for people with intellectual disabilities, a state-supported living center or state hospital.

Liquid Resources - Cash or financial instruments that can be converted to cash within 20 workdays.

Medicaid eligible - A person who receives federal medical assistance, such as SSI, TANF, medical assistance only (MAO), or through a federally approved waiver while living in the community.

Medicare eligible - A person who receives Social Security or railroad retirement benefit payments and meets eligibility criteria to have certain medical expenses paid by the federal Medicare program.

Neglect - The failure to provide oneself the goods or services, including medical services, necessary to avoid physical or emotional harm or pain or the failure of a caretaker to provide the goods or services.

Person with disabilities - A person who, because of physical, mental, or developmental impairments, is limited temporarily or permanently in their capacity to adequately perform one or more essential activities of daily living. This includes, but is not limited to, personal and health care, moving around, communicating, and housekeeping.

Personal leave - Any leave from a residential care facility except for hospitalization or institutionalization. A day of personal leave is any period of 24 consecutive hours.

Primary Home Care (PHC) - A non-technical, medically related personal care service available to people eligible for Medicaid whose health problems limit their ability to perform activities of daily living, per a practitioner’s statement of medical need.

Prior approval - A regional nurse’s authorization to a provider agency to deliver services when a person meets the medical need criteria for the requested service.

Provider agency - An agency contracted with HHSC to provide programs or services that CCSE has authorized for people eligible for services.

Recipient - A person receiving CCSE services. May also be called a client.

Regional nurse - A registered nurse employed by HHSC who authorizes CAS, PHC and DAHS services.

Residential Care (RC) - Delivers a 24-hour living arrangement in a licensed facility that provides personal care, home management, escort, social and recreational activities, transportation, 24-hour supervision, and supervision of or help with the direct administration of medication.

Resource - Any cash or other liquid assets or any real or personal property owned by a person or their spouse that can be converted to money for support and maintenance.

Responder - A person who responds to an Emergency Response Services (ERS) call activated by a recipient. Responders may include relatives, neighbors, volunteers, or staff of a sheriff’s department, police department, emergency medical service or fire department.

Responsible person - A person who is:

• an applicant or recipient’s parent or legal guardian; or
• anyone an adult applicant or recipient designates as their representative.

Routine Response - An initial visit, either by phone or in-person, for services of an applicant by the caseworker within 14 calendar days from the date of assignment. Review 2320 in the handbook.

Special Services to Persons with Disabilities (SSPD) - Provides services in various settings to help people develop the skills needed to live independently in the community. The service plan includes counseling, personal care, and developing skills for independent living in the community. Services vary depending on the regional contract.

Supplemental Security Income (SSI) - Monthly payments made by the Social Security Administration (SSA) to people with disabilities and older adults with little or no income or resources. The Social Security Administration (SSA) decides eligibility for SSI.

Unearned income - Income from sources other than self-employment or employee work activities.

Unmet need - A requirement for help with daily activities that cannot be met adequately by friends, relatives, volunteers, or other service agencies or programs.

1140 Disclosure of Information

Revision 17-1; Effective March 15, 2017

1141 Confidential Nature of the Case Record

Revision 24-4; Effective Sept. 1, 2024

Information collected to determine initial or continuing eligibility is confidential. The restriction on disclosing information is limited to information about people. HHSC may disclose general information about policies, procedures, or other methods of determining eligibility and any other information that is not about or does not specifically identify a person.

A person may review all information in the case record and in HHSC handbooks that contributed to the decision about their eligibility.

1141.1 Confidential Information on Notifications

Revision 24-4; Effective Sept. 1, 2024

HHSC is committed to protecting all confidential information supplied by the applicant or person during the eligibility determination process. This includes confidential information by HHSC staff to third parties who receive a copy of a notification of eligibility form. Staff must ensure they do not include confidential information on the eligibility notice that should not be shared with the service provider or another third party.

Example: A person is being denied family care (FC) due to an increase in income. It is a violation of confidentiality to record on Form 2065-A, Notification of Community Care Services, your income of $2,892 exceeds the eligibility limit of $2,829. The comment should state, "Your income exceeds the eligibility limit."

Another applicant is denied primary home care (PHC) services because they do not meet the medical diagnosis criterion. It is a violation of confidentiality to record on Form 2065-A, "Your diagnosis of schizophrenia does not meet the medical diagnosis criteria for eligibility for the Primary Home Care Program." The comment should state, "You do not have a medical diagnosis resulting in a functional limitation, as required for eligibility."

In the examples above, revealing the amount of the person’s’ income or diagnosis violates their right to confidentiality. In all cases, HHSC staff must assess any information provided by the person to determine if its release would be a confidentiality violation.

1142 Establishing Identity for Contact Outside the Interview Process

Revision 24-4; Effective Sept. 1, 2024

HHSC must keep all information about a person or any person on the case confidential. Confidential information includes, but is not limited to, individually identifiable health information.

Before discussing or releasing information about a person or any person in the case, ensure whoever is receiving the confidential information is either the person or someone the person has authorized to receive confidential information. Example: attorney or personal representative.

1142.1 Phone Contact

Revision 24-5; Effective Nov. 1, 2024

Before discussing or releasing case information over the phone, establish the caller’s identity.

For callers who claim to be the applicant or recipient or the applicant’s or recipient’s personal or authorized representative (AR), establish identity by using the caller’s knowledge of the applicant’s or recipient’s:

• SSN;
• date of birth;
• other identifying information; or
• knowledge of the same information about the applicant’s or recipient's representative.

Establishing the caller’s identity can also be done by calling the applicant or recipient to confirm the identity of the caller.

Establish the identity of attorneys or legal representatives by asking:

• the legal representative to provide a complete Form H1826, Case Information Release, signed by the recipient; and
• the ARs to provide a complete and signed Form H1003, Appointment of an Authorized Representative.

1142.2 In-Person Contact

Revision 24-4; Effective Sept. 1, 2024

Establish the identity of someone who presents themself as a person or a person’s representative at an HHSC office by using sources such as:

• driver's license;
• date of birth;
• Social Security number; or
• other identifying information.

Establish the identity of other HHSC staff, federal agency staff, researchers, or contractors by using sources such as:

• employee badge; or
• government-issued identification card with a photograph.

Identify the need for other HHSC, federal or research staff, or contractors to gain confidential information through:

• Official correspondence or a phone call from a state or regional office.
• Contact with a regional attorney.

Contact appropriate regional or state office staff when federal agency staff, contractors, researchers, or other HHSC staff come to the office without prior notification or adequate identification and request permission to access HHSC records.

1142.3 Verification and Documentation

Revision 24-5; Effective Nov. 1, 2024

If disclosing individually identifiable health information, document how the person’s identity is verified when contact is outside the interview.

Verify the identity of the person who requests disclosure of individually identifiable health information using sources such as:

• valid driver's license or Department of Public Safety ID card;
• birth certificate;
• hospital or birth record;
• adoption papers or records;
• work or school ID card;
• voter registration card;
• wage stubs; or
• U.S. passport.

1143 Custody of Records

Revision 24-5; Effective Nov. 1, 2024

Records must be safeguarded. Use reasonable diligence to protect and preserve records and to prevent disclosure of the information in them, except per HHSC regulations.

Reasonable diligence for employees responsible for records includes keeping records:

• in a locked office when the building is closed;
• properly filed during office hours; and
• in the office at all times, except when authorized to remove or transfer them.

1144 Disposal of Records

Revision 24-4; Effective Sept. 1, 2024

Follow the HHSC procedures for the destruction of confidential data in the Records Management Manual to dispose of documents with person-specific information.

1145 When and What Information May Be Disclosed

Revision 24-4; Effective Sept. 1, 2024

Staff must make reasonable efforts to limit the use or disclosure of individually identifiable health information to the minimum necessary to determine eligibility and operate the program. Limit the disclosure of a person’s medical information from HHSC records to the minimum required to complete the requested disclosure.  Example: If a person authorizes the release of income verification, including disability income, do not release related case medical information unless specifically authorized by the person.

Do not respond to inquiries from the applicant or recipient’s relatives or friends requesting addresses or personal information without the applicant or recipient’s consent. Inform the applicant or recipient of any inquiries. Allow the applicant or recipient to determine if they wish to share the information before providing it to the inquiring party.

The applicant or recipient authorizes the release of information by completing and signing:

• Form H1826, Case Information Release; or
• a document with all the following information:
  • the person's full name including middle initial and case number, or full name including middle initial and either their date of birth or Social Security number;
  • a description of the information to be released;
    • if a general release is authorized, provide the information that can be disclosed to the person; and
    • withhold confidential information from the case record, such as names of people who disclosed information about the household without the household's knowledge, and the nature of pending criminal prosecution;
  • a statement specifically authorizing HHSC to release the information;
  • the name of the person or entity to whom the information can be released;
  • the purpose of the release;
  • an event that triggers an expiration of the authorization or an expiration date of the release;
  • a statement about if refusal to sign the release affects eligibility for delivery of services;
  • a statement describing the person's right to revoke the authorization to release information;
  • the date the document is signed; and
  • the signature of the person or legally authorized representative (LAR).

If the case information to be released includes individually identifiable health information, clearly indicate in the document that the applicant or recipient understands information released may no longer be private and may be released again by the person receiving the information.

When information is requested from the case records of a deceased person, the privacy of the deceased person and their survivors must be protected. Follow policy to determine who can act on behalf of a deceased person about individually identifiable health information.

Do not include Form H1826 or other information or release authorization documents in application packets.

The HHSC Office of the Chief Counsel handles questions about the release of information under the Open Records Act. Refer all questions and issues encountered by people about release of information to the Open Records Division, Office of the Chief Counsel. Regional staff should direct questions and issues to the regional attorney.

Follow Confidential Nature of Medical Information – HIPAA policy for restrictions on the release of a person's protected health information under the Health Insurance Portability and Accountability Act (HIPAA) privacy regulations.

Related Policy

1145.1, Request for Release of Information Related to a Deceased Individual
1146, Confidential Nature of Medical Information – HIPAA

1145.1 Request for Release of Information Related to a Deceased Person

Revision 24-5; Effective Nov. 1, 2024

This section shows how to handle requests for releasing information  when a request for information about the Medicaid Estate Recovery Program (MERP) occurs for a deceased applicant or person. HHSC does not provide a form to document when someone requests information. Instead of a form, use one of the following methods to document the request for this type of release of information to the requestor:

• a release form or statement signed by the applicant or person before death and not revoked by the applicant or person authorizing the release of information to the specific person requesting the information;
• a copy of an order from a probate court appointing the requestor as an estate administrator or guardian;
• a copy of another type of order from a court authorizing the requestor to administer the deceased affairs; or
• documentation demonstrating the requestor has authority under Texas law to act for the deceased.

A person with authority under Texas law to act on behalf of a deceased applicant, person or the deceased's estate includes a surviving spouse, an adult child, a parent or an heir.

Regional staff should ask the requestor for any available document, noted above. If a document is not available, staff must determine and document if the requestor has authority under Texas law to act for the deceased applicant or person. Regional staff may release information to the requestor if one of the documentation requirements above is met and filed or recorded in the case record.

1146 Confidential Nature of Medical Information – HIPAA

Revision 24-5; Effective Nov. 1, 2024

Health Insurance Portability and Accountability Act (HIPAA) is a federal law that sets additional standards to protect the confidentiality of individually identifiable health information. Individually identifiable health information is information that identifies or could be used to identify a person. It relates to the following:

• past, present, or future physical or mental health or condition of the person;
• provision of health care to the person; or
• past, present, or future payment for health care to the person.

1147 Privacy Notice

Revision 25-3; Effective June 1, 2025

HIPAA requires HHSC to provide a notice of privacy practices that explains:

• the person’s privacy rights;
• the duties of HHSC to protect the person’s health information; and
• how HHSC may use or disclose the person’s health information without authorization.

Example: HHSC may share health information with the person’s provider to arrange for services or  with other government entities to report suspected abuse, neglect or exploitation (ANE).

Provide Form 0401, Notice of Privacy Practices (English PDF), or Form 0401-S, Aviso de Normas Sobre la Privacidad (Spanish PDF), as appropriate, to each person enrolled in a Title XX program who is not categorically financially eligible.

Provide Form 0401 or Form 0401S to each Title XX applicant:

• at initial certification; and
• at recertification after a break in services of more than 180 days.

Note: Categorically eligible applicants receive notice of privacy practices from AES eligibility staff at certification and recertification.

Form 0403, Explanation to Health Information Privacy Rights (PDF), provides a reminder of privacy practices and where to find Form 0401.

Provide Form 0403 in person during the home visit or by mail to each Title XX recipient:

• at each annual recertification;
• after a break in services of at least 30 calendar days but not more than 180 days or
• when a new person is added to a case.

1148 Reserved for Future Use

Revision 21-4; Effective December 1, 2021

1149 Minimum Necessary

Revision 24-5; Effective Nov. 1, 2024

Make reasonable efforts to limit the use, request, or disclosure of individually identifiable health information to the minimum necessary to determine eligibility and operate the program. The disclosure of a person’s medical information from HHSC records must be limited to the minimum required to accomplish the requested disclosure. Example: If a person authorizes the release of income verification, including disability income, do not release related case medical information unless specifically authorized by the person.

1150 Personal Representatives

Revision 25-3; Effective June 1, 2025

Only the person or their personal representative can exercise the person’s right concerning individually identifiable health information. Therefore, only the person or their personal representative may authorize the use or disclosure of individually identifiable health information or get individually identifiable health information for a person.

Exception: HHSC is not required to disclose the information to the personal representative if the person is subjected to domestic violence, abuse, neglect or exploitation (ANE) by the personal representative. Consult the regional attorney if it is believed that health information should not be released to the personal representative.

Note: A responsible party is not automatically a personal representative.

1151 Adults and Emancipated Minors

Revision 24-5; Effective Nov. 1, 2024

If the person is an adult or emancipated minor, including married minors, the person’s personal representative is someone with the authority to make health care decisions about the person and includes:

• someone the person has appointed under a medical power of attorney, a durable power of attorney or a power of attorney with authority to make health care decisions;
• a court-appointed guardian for the person; or
• someone designated by law to make health care decisions when the person is in a hospital or nursing home and is incapacitated or mentally or physically incapable of communication. Follow regional procedures to contact the regional attorney for approval.

1152 Unemancipated Minors

Revision 24-5; Effective Nov. 1, 2024

A parent is the personal representative for a minor child except when:

• The minor child can consent to medical treatment by themselves. In this circumstance, do not disclose the medical treatment to a parent. A minor child can consent to medical treatment by themselves when the:
  • minor is on active duty with the U.S. military;
  • minor is 16 or older, lives separately from the parents, and manages their own financial affairs;
  • consent involves diagnosis and treatment of disease that must be reported to local health officer or state health services;
  • minor is unmarried and pregnant, and the treatment relates to the pregnancy;
  • minor is 16 or older, and the consent involves examination and treatment for drug or chemical addiction, dependency, or use at a treatment facility licensed by the Texas Council on Alcohol and Drug Abuse;
  • consent involves examination and treatment for drug or chemical addiction, dependency, or use by a physician or counselor at a location other than a treatment facility licensed by the Texas Council on Alcohol and Drug Abuse;
  • minor is unmarried, is the parent of a child, has actual custody of the child, and consents to treatment for the child; or
  • consent involves suicide prevention or sexual, physical, or emotional abuse.
• A court makes health care decisions for minor children or has given the authority to make health care decisions for minor children to an adult other than a parent or to the minor child. Under these circumstances, do not disclose to a parent information about the health care decisions not made by the parent.

1153 Deceased People

Revision 24-5; Effective Nov. 1, 2024

The personal representative for a deceased person is an executor, administrator, or other person with authority to act on behalf of the person or the person’s estate. These include:

• an executor, including an independent executor;
• an administrator, including a temporary administrator;
• a surviving spouse;
• a child;
• a parent; and
• an heir.

Contact the regional attorney if you have questions about whether a certain person is the personal representative of an applicant or person.

1160 Correcting Information

Revision 24-5; Effective Nov. 1, 2024

A person has a right to correct any information that HHSC has about them and any other person on their case.

A request for correction must be in writing and:

• identify the person asking for the correction;
• identify the disputed information about the person;
• state why the information is wrong;
• include any proof that shows the information is wrong;
• state what correction is requested; and
• include a return address, phone number, or email address where HHSC can contact the person.

If HHSC agrees to change individually identifiable health information, the corrected information is added to the case record. The incorrect information remains in the file with a note that the information was amended per the person's request.

Notify the person in writing within 60 days, using current HHSC letterhead, that the information is corrected or will not be corrected and the reason. Inform the person if HHSC needs to extend the 60 days by an additional 30 days to complete the correction process or get more information.

If HHSC corrects individually identifiable health information, ask the person for permission before sharing it with third parties. HHSC will make a reasonable effort to share the correct information with people who received the incorrect information from HHSC if they may have relied on it or could rely on it to the person’s disadvantage. Follow regional procedures to contact the HHSC Privacy Officer for a record of disclosures.

Note: Do not follow the above procedures when the accuracy of information provided by a person is determined by another review process, such as a:

• fair hearing;
• civil rights hearing; or
• other appeal process.

The decision in that review process is based on the request to correct information.

1170 Alternate Means of Communication

Revision 24-5; Effective Nov. 1, 2024

HHSC must accommodate a person's reasonable requests to receive communications by alternative means or at alternate locations.

The person must specify in writing the alternate mailing address or means of contact. They must include a statement that using the home mailing address or regular means of contact could endanger the person.

2110 Description of Case Management

Revision 25-4; Effective Sept. 1, 2025

26 Texas Administrative Code Section 271.79 says people must meet the eligibility criteria for CCSE services and can receive case management without receiving services. Ineligible applicants who receive only information and referral are not eligible for case management.

Case management is a set of actions a Texas Health and Human Services Commission (HHSC) caseworker takes to determine:

• if a person who requests service is eligible for HHSC services;
• what services the person needs; and
• who will provide those services.

Case management also includes:

• referring eligible people to service providers and facilitating the referral;
• monitoring the referral to make sure the services are initiated;
• monitoring the services to make sure the person's needs are being met; and
• periodically reviewing the person's situation to confirm ongoing eligibility and to identify any changes.

2120 Case Management Process

Revision 24-3; Effective July 1, 2024

Case management involves six single functions.

1. Intake — Requests for service or information are made by the person or someone on the person's behalf by phone, letter, or in-person. Texas Health and Human Services Commission (HHSC) intake staff:
   • determine the precise request;
   • record certain information from the requester;
   • give the requester certain information;
   • determine if an immediate, expedited, or routine response is necessary; and
   • refer the request to the appropriate unit for further action.
     Review 2200, Intake Procedures for detailed intake procedures.
2. Assessment — HHSC caseworkers respond to intake by visiting the person at home or in another setting to assess eligibility and needs. The assessment process includes:
   • determining financial eligibility;
   • determining functional eligibility for the performance of activities of daily living;
   • assessing the person's home, social, and environmental supports, and resources;
   • determining services the person needs and if family or community resources are currently meeting those needs; and
   • assessing the person's physical condition and determining if that condition and their environment pose any risk.
     Review 2400, Assessment Process for detailed assessment procedures.
3. Service planning — Caseworkers develop a service plan with each eligible person after completing the assessment. Service planning includes:
   • determining what services and environmental adaptations are required to satisfy the person's personal unmet needs, health, and safety;
   • determining and specifying what services will be secured from whom or from where, how much will be provided, and on what schedule;
   • specifying how often the caseworker will monitor the provision of services and personal satisfaction; and
   • getting the person's agreement with the service plan.
     Review 2500, Service Planning for detailed service planning procedures.
4. Service authorization
   1. Non-Medicaid services — If non-Medicaid HHSC services need purchasing as part of the service plan, the caseworker:
      • authorizes the services per program policies and procedures;
      • sends the service plan and person’s referral information to the provider selected by the person; and
      • discusses the plan with the potential provider, as necessary.
   2. Medicaid services — If Medicaid services need purchasing as part of the service plan, the caseworker:
      • designates the services per Medicaid program policies and procedures;
      • if necessary, gets consultation from the regional nurse about medical need for services;
      • sends the service plan and person’s referral information to the provider selected by the person;
      • discusses the plan with the provider supervisor, if requested; and
      • discusses the plan with the regional nurse, as necessary.
        Review 2600, Authorizing and Reassessing Services for detailed service authorization procedures.
5. Service monitoring and evaluation — The caseworker:
   • contacts each person after service referral, per case management requirements, to ensure that services were initiated as scheduled and to determine the person's satisfaction with the service;
   • contacts and visits each person per the individualized case management plan or upon request by the person or others;
   • accompanies regional nurses on utilization review home visits when requested;
   • evaluates the person's condition, needs, and service provision on an ongoing basis, per HHSC procedures and individual requirements;
   • requests consultation and joint home visits with the regional nurse, provider nurse, or both when indicated because of the person's health condition or risk status;
   • receives information from providers about the person's ongoing needs and conditions; and
   • reassesses a person's needs and reviews and reauthorizes service plans per required schedules.
     Review 2700, Service Monitoring, Changes, and Transfers, for detailed procedures concerning service monitoring.
6. The caseworker is also responsible for helping people who have lost their Your Texas Benefits (YTB) Medicaid card or never received it. Review 2130, Your Texas Benefits Medicaid Card and Replacement, for detailed procedures.

2130 Your Texas Benefits Medicaid Card and Replacement

Revision 24-5; Effective Nov. 1, 2024

Form H3087, Medicaid Identification, is no longer issued and was replaced by the Your Texas Benefits (YTB) Medicaid card.

The YTB Medicaid card is a plastic card. Providers must verify eligibility before providing services, as the card does not prove ongoing Medicaid eligibility. Medicaid recipients must take the card to doctor or dental appointments and the pharmacy. This card is for permanent use, and the Texas Health and Human Services Commission (HHSC) only issues a new card if it is lost or if the information printed on it changes.

The person may call 855-827-3748 if the card is lost and they need a replacement card. Medicaid providers and pharmacies can verify eligibility by phone using a provider-dedicated line. So, even if a card is lost, the Medicaid recipient can receive services or fill a prescription. The card should not be thrown away, even if the recipient is denied Medicaid, since the card will be reused if the person regains eligibility.

Requesting Form H1027-A, Medicaid Eligibility Verification

Form H1027-A, Medicaid Eligibility Verification, is a secure form. It is not available on the website and must be ordered. However, the form instructions are available on the Texas Health and Human Services forms webpage to complete the form. Designated HHSC staff may continue to help people in the following situations:

• Ongoing Medicaid Recipients — HHSC staff may help with a manual Form H1027-A upon request because the recipient lost or did not receive the YTB Medicaid card. HHSC staff issuing Form H1027-A should inform the recipient of the following:
  • Call 855-827-3748 for a replacement card.
  • The burden of verifying Medicaid eligibility is with the provider.
  • A person who is Medicaid eligible, but does not have written proof of eligibility, should still be able to get services from their provider or to fill a prescription.
  • Medicaid providers and pharmacies can verify eligibility by phone using a provider-dedicated line or the Texas Medicaid & Healthcare Partnership (TMHP) TexMedConnect website.
• New Medicaid Recipients — Eligibility information is not immediately available for providers or pharmacies to verify after Medicaid is approved. HHSC staff must refer the recipient to the HHSC Benefits office to issue Form H1027-A between the time eligibility is determined and the time eligibility is available in the online system.

Once the recipient receives the replacement card, they present it to the Medicaid provider or pharmacy when services are requested. The recipient may call 800-252-8263 or 2-1-1 to confirm Medicaid coverage if they are not sure of their eligibility status.

More information about the new card is available at www.yourtexasbenefits.com.

2210 Requests for Services

Revision 24-5; Effective Nov. 1, 2024

A request for services may begin with

• phone or written referrals from other agencies, organizations, and HHSC divisions; or
• phone, written, or walk-in requests from people or their relatives, friends, or other interested people.

2211 Applications and Referrals Routed from the Austin Document Processing Center

Revision 24-3; Effective July 1, 2024

When the Austin Document Processing Center (DPC) receives an application requesting a Community Care Services Eligibility (CCSE) referral, the DPC will fax the first three pages of the application and a cover sheet to the CCSE local office. CCSE staff reviews each of the referrals and contacts the person to determine if the person is interested in CCSE services. They then take the following actions:

If it is determined the person is interested in a CCSE program without an interest list, CCSE staff:

• Completes an intake for the services requested and accesses the HHSC Benefits Portal.
• Prints out the rest of the application.
• Clicks on the PT Inquiry tab and opens the PT inquiry.
• Clicks on Inbound Correspondence Image Repository Search and searches for the person.
• Selects the appropriate document and clicks view.
• When the PDF document opens, click on the printing icon to print the document.

If the person is only interested in a program with an interest list, the person will be placed on the interest list, and staff will not need to print the remainder of the application.

If the person is not interested in a CCSE program or a program with an interest list, file the fax from DPC following local office procedures.

The document processing center address is:
Document Processing Center
P.O. Box 149024
Austin, TX 78714-9024
Fax Number: 877-236-4123

2220 Response to Requests for Service

Revision 25-2; Effective March 31, 2025

When a service request is received by phone, written referral, or in person, the HHSC staff who conducts intake for community care services or who receives a service request gives the requester information about HHSC CCSE services. Then they determine what service is being requested and if HHSC provides that service.

Once a written or faxed referral is received, the applicant or responsible party may be contacted by intake staff, or the referral may be accepted, entered in the Intake (NTK) system, and assigned to a caseworker. The caseworker would then make the initial contact, provide information about HHSC, and screen for appropriate services.

The intake staff or caseworker who conducts intake for community care services or who receives a service request:

• gives the requester information about HHSC, including CCSE services, as needed;
• determines what service is being requested and if HHSC provides that service;
• refers the request for non-HHSC services to the appropriate state or community agency and documents the request;
• refers people who are currently in nursing facilities and still require skilled services, but would like to return to the community to STAR+PLUS Home and Community Based Services (HCBS);
• transfers to appropriate staff any requests for HHSC services other than community care services;
• identifies reports of suspected need for Adult Protective Services (APS) and immediately provides these reports to APS staff;
• gets eligibility-related financial information about the applicant; and
• gives the requester general information about CCSE eligibility, emphasizing that exact eligibility information cannot be given until a caseworker interviews the person.

If the requester does not want to apply for CCSE services, the requester is transferred to the appropriate staff for requests for HHSC services other than community care services or referred to other relevant resources. Review Appendix XV, Services Available from Other State Agencies, and 2530, Other Resource Services. The information is not entered into NTK, and an intake is not completed. This information is recorded in an Information and Referral Log.

If the person wants to apply for CCSE services, the intake person:

• completes the intake by entering the information into the automated system for intakes or completes Form 2110, Community Care Intake, per the form instructions, completing only the required sections if some information is not available;
• documents on the form or a log any requests for information and referral per regional procedures;
• refers walk-in requesters to the appropriate unit for the completion of applications;
• determines if the requester can and will complete an application for the applicant;
• identifies a responsible party who will help with the application process;
• identifies and documents which people have no relative or responsible person to help with the application process;
• assesses the urgency of the request and immediately routes all requests to appropriate units for further action. Review 2310, Criteria for Immediate or Expedited Responses to Service Requests; and
• informs the requester that a caseworker will contact the applicant to discuss the application process further.

For all people who currently do not receive Supplemental Security Income (SSI) or SSI-related Medicaid and are requesting personal attendant services (PAS), the intake screener must assign the intake to a caseworker as an application for Community Attendant Services (CAS). Intake screeners must not screen applicants for a specific service or determine if an applicant should only be assigned for Family Care or placed on the interest list for Family Care services. The intake screener does not place the person’s name on the Family Care interest list. The caseworker determines if the person will be placed on the interest list, as described below.

All people not currently receiving Medicaid and wish to apply for PAS must be seen by a caseworker and assessed for CAS. During the initial interview, the caseworker screens all applicants for potential eligibility for CAS and determines if the applicant will be referred to MEPD for CAS.

Certain services require special intake procedures. For details, review 4000, Specific CCSE Services.

2221 Requests for STAR+PLUS Services

Revision 25-5; Effective Dec. 1, 2025

When the Health and Human Services Commission (HHSC) receives a request for services, staff must assess if the request should be forwarded for processing to the:

• appropriate HHSC STAR+PLUS department; or
• managed care organization (MCO).

Refer to the charts in the STAR+PLUS Handbook for more information.

People awaiting managed care enrollment may be assessed for interim services from Community Care Services Eligibility (CCSE).

CCSE will enroll mandatory STAR+PLUS people in Primary Home Care (PHC) if they meet either of the following criteria:

• PHC immediate or expedited criteria, described in 2310, Criteria for Immediate or Expedited Responses to Service Requests; or
• intake criteria was routine, but they became eligible for Medicaid after the initial home visit has been completed.

Once notified that the recipient has been enrolled with an MCO, CCSE staff must terminate PHC effective the day before the enrollment begin date.

CCSE will enroll people who have been discharged from a nursing facility into PHC if they have active Medicaid Eligibility (ME) Nursing Facility Medicaid, pending determination of Community Attendant Services (CAS) by Medicaid for the Elderly and People with Disabilities (MEPD).

Mandatory STAR+PLUS people who are not yet enrolled with an MCO, and do not meet any of the above criteria, will be referred to the Enrollment Broker. People who are already enrolled with an MCO and request PHC or Day Activity and Health Services (DAHS) from CCSE must be advised to contact their MCO.

CCSE will not enroll people in DAHS when they are listed in TIERS as candidates for STAR+PLUS enrollment. Since there are no immediate or expedited criteria for DAHS enrollment, people seeking these services will be available upon enrollment for the STAR+PLUS program. DAHS facility-initiated referrals that take place for people pending STAR+PLUS enrollment will not be reimbursed by HHSC.

Refer to the STAR+PLUS Handbook, 3221, Mandatory Groups, and 3222, Excluded Groups for a list of mandatory and non-mandatory STAR+PLUS participants.

2222 Reinstatement Procedures for People Reapplying for Services After Loss of Financial Eligibility

Revision 24-3; Effective July 1, 2024

If a person has lost categorical or financial eligibility, creating a gap in service, the following procedures apply.

If financial or categorical eligibility is re-established within 60 days of the denial date and the person reapplies for services, the caseworker may use the current information on file to determine eligibility. A new Form 2110, Community Care Intake, must be completed. The caseworker must note in the Comments section of Form 2110 that reinstatement procedures are being used within 60 days of the denial date.

Review 3441.2, Reinstatement Procedures After Denial, for complete procedures.

2223 Caregiver Support Assessment Initiative

Revision 24-5; Effective Nov. 1, 2024

Background

Senate Bill (SB) 271, 81st Legislature, Regular Session, 2009, relating to informal caregiver support services, directs Texas Health and Human Services Commission (HHSC) staff to:

• raise awareness of services available to caregivers;
• perform outreach functions to informal caregivers; and
• gather information about the needs of caregivers, including the:
  • collection of profile data on informal caregivers;
  • referral provided to support services, when appropriate; and
  • implementation of a standardized caregiver assessment tool to evaluate the needs of caregivers.

SB 271 requires HHSC to use the information collected to refer informal caregivers to available support services and to:

• evaluate the needs of assessed informal caregivers;
• measure the effectiveness of certain informal caregiver support interventions;
• improve existing programs;
• develop new services, as necessary, to sustain informal caregivers; and
• determine the effect of informal caregiving on employment and employers.

The Caregiver Status Questionnaire (CSQ) is designed to meet the requirements of SB 271. The information collected is analyzed and included in the HHSC report to the governor and the Legislative Budget Board. HHSC is required to submit this report in December of each even-numbered year, beginning Dec. 1, 2012.

Completion of the CSQ

The CSQ is available in the Long-Term-Care Services Intake (NTK) System. When possible, it is completed at the time of the intake contact. The CSQ and a script for the interview are available in English and Spanish in Appendix XXXVIII, Caregiver Support Assessment Initiative. If not feasible, one more contact with the caregiver must be attempted within five business days. If it is necessary to go beyond the five-business-day period, document the reason in the comments section of the CSQ. When a follow-up contact is made, enter the date in the top right corner of the CSQ, just under the NTK menu bar. Check the appropriate box to show if the attempt to contact failed or the caregiver declined to participate.

Staff should always assume there is no assessment and proceed as usual. If the caller states they have completed the caregiver assessment in the past, staff should not ask them to complete the assessment again. Staff may exit the caregiver screen by selecting yes at the top of the page to the question: Caregiver declined to answer?. In the comments section at the bottom of the page, document that an assessment has already been conducted for that caregiver.

The purpose of the CSQ is to collect the information described above. This information is not used to determine if the unmet need criteria for Community Care Services has been met and will not be forwarded to the caseworker.

Question Sensitivity

Some staff may find asking some of the questions on the CSQ is awkward. While understandable, all the questions must be asked, and a response recorded. It is not acceptable to skip a question. If a person seems resistant to answering any of the questions, do not insist on a response. Document the person’s refusal to answer and continue to the next question.

Caregiver Employment

Checkboxes are provided to record how caregiving responsibilities affected the caregiver's employment. After asking the open-ended question, listen to the caregiver's comments and check all the applicable boxes. You are not expected to read aloud each possible response to the employment question. However, the list can be used as a prompt if the responder is unsure how to answer aloud. If the person seems uncertain, you may read the response category headings. Example:  Has caregiving affected your employment schedule, pay, leave, performance or work relationships?  If further clarification is necessary, you may ask the question differently. Example: Have you had to take extra leave or change your work schedule to meet your caregiver responsibilities?

Referral to the Area Agency on Aging (AAA)

If the person meets one of the following criteria, they may qualify for services from the AAA. If the person would like help, refer per regional procedures.

AAA Eligibility Screening Criteria

The person may qualify for services from AAA if the person is:

• 60 or older and is caring for a person of any age;
• 55 or older and is caring for a grandchild under 18 in their home because:
  • the biological or adoptive parents are unable or unwilling;
  • they have legal custody or guardianship or are raising the child informally;
  • they are caring for a person 19-59 living with severe disabilities; or
  • they are a caregiver for a person of any age who has Alzheimer's or dementia.

Accessing the CSQ

Use the manual copy of the CSQ when the automated system is unavailable. However, all information must be entered into the automated system as soon as possible. The version of the CSQ, which includes a script and instructions on recording responses, may be helpful for staff completing the CSQ for the first few times. Follow the instructions below to complete the CSQ.

1. Conduct intake per usual procedures using the NTK system.
2. Document if the person requesting services has a caregiver at the Client Information screen. If there is a caregiver, the CSQ must be completed at the end of the intake process if the caregiver is available. If the caregiver is not available, document the caregiver’s contact information. At least one follow-up attempt must be made to contact the caregiver later.
3. Select the Caregiver tab on the NTK section selection menu.
4. Enter the information on the Caregiver screens, as requested.
5. At the end of the CSQ, if the person requesting services may qualify for services from the AAA, make a referral following regional procedures.

The collection of legislatively mandated information enables the state to refer caregivers to available support services and to develop more services to meet caregiver needs.

2230 Interest List Procedures

Revision 26-2; Effective June 1, 2026

People who express interest in a community services program with an interest list are registered on the Community Services Interest List (CSIL), regardless of the program’s enrollment status. CSIL records the date and time of the expressed interest. If the person is first on the list and the region is releasing and enrolling for that program, the person may be immediately released and assigned for the enrollment process.

If no Title XX funds are available, talk with the person to decide if their needs can be met through other services. If the person agrees, add their name to the appropriate interest lists. Enter the information in the CSIL system if no other service is available or suitable.

People who request placement on an interest list must live in Texas. An out-of-state address can be used as a contact if the power of attorney, guardian or legally authorized representative lives out of state. Other exceptions may be made for people placed on an interest list while living in Texas, who then move temporarily out of the state because of military assignments.

People on military assignments who are temporarily out of state include:

• Military member – A member of the U.S. military serving in the Army, Navy, Air Force, Marine Corps or Coast Guard on active duty who has declared and maintained Texas as the member's state of legal residence in the manner provided by the applicable military branch;
• Military family member – A person who is the spouse or child, regardless of age, of a military member or a former military member; or
• Former military member – A person who served in the U.S. Army, Navy, Air Force, Marine Corps or Coast Guard who declared and maintained Texas as the person’s state of legal residence in the manner provided by the applicable military branch while on active duty or who was killed in action or died while in service, or whose active duty otherwise ended.

People are released from the interest list on a first-come, first-served basis. Eligibility determinations are conducted when a person is released from the interest list.

When a person on an interest list transfers from one region to another, they must be added to the receiving region's list. Use the original intake date for the service as documented by the losing region. The staff person who first becomes aware that the person has transferred to another region, whether losing or gaining, must notify the other region. This makes sure both regions' lists are accurate.

When a person is released from the interest list, the caseworker must contact the person to determine their continued interest in services. If the person is interested, the caseworker must schedule a home visit if required by the service. If the person is no longer interested in services and voluntarily withdraws, the caseworker enters the appropriate CSIL closure code in the CSIL system. No entries in the Service Authorization System Online (SASO) are required, and Form 2065-A, Notification of Community Care Services, is not sent.

During routine interest list contacts, remove people on the interest list who do not live in Texas. Inform them they must be a resident of Texas to be on an interest list. Exceptions may be made for people on military assignments who are temporarily living out of state.

If the person is interested in services, the case will be processed as a routine intake.

Refer to the following for more information about the CSIL system:

2231, Community Services Interest List Bypass Criteria; and

2232, The Community Services Interest List System.

Note: The Area Agencies on Aging (AAA) can refer people to available services. Service needs, resources and available service providers vary across the state. Not all services identified by AAA may be available in every area. The applicant or person should contact the local AAA to find out if a specific service is available. Call 800-252-9240 to find the phone number for the local AAA.

When the Texas Health and Human Services Commission (HHSC) intake staff determine a request is for STAR+PLUS Home and Community Based Services (HCBS), they must inform the person they can add themselves to the STAR+PLUS HCBS interest list at YourTexasBenefits.com or by calling 844-438-5658.

2230.1 Adding a Person's Name Back to CSIL

Revision 24-5; Effective Nov. 1, 2024

A person's name may be added back to the Community Services Interest List (CSIL) at any time within 90 calendar days after the CSIL service has been closed if the person contacts the Texas Health and Human Services Commission (HHSC):

• within 90 calendar days of the closure date, the original date of request can be used; or
• more than 90 calendar days following the closure date, the current date must be used.

If a CSIL closure occurred during release or assigned status and the person is added back to the interest list, the name may be released for eligibility determination, as needed, to ensure the region is fully utilizing its funding.

Any exceptions for adding names back to CSIL with the original date after 90 calendar days must be approved by the state office CSIL manager.

When an applicant or person has been denied for a service, the earliest date the applicant or person may be added back to CSIL for the same program is the date the applicant or person is determined to be ineligible or is no longer eligible for the program.

If the person's name is added back to CSIL before the last date of program eligibility, the CSIL interface match with the Service Authorization System Online (SASO) will cause the name to be removed from the interest list for that program. Example: A person's Family Care (FC) services are denied and end on Aug. 13, 2024. The first date the person can be added back to the FC interest list is Aug. 14, 2024. If the person is already on the Home-Delivered Meals (HDM) Interest List, the denial date for FC services would not impact the person's original date on the HDM Interest List.

2231 Community Services Interest List Bypass Criteria

Revision 24-5; Effective Nov. 1, 2024

Under certain circumstances, people can bypass the interest list to start the enrollment process. The bypass must meet specific criteria and be approved by the regional director.

2231.1 People Who May Receive Title XX Services with Regional Director Approval

Revision 24-5; Effective Nov. 1, 2024

A person may be given a bypass code to be placed at the top of the interest list, in the following circumstances. The regional director decides if the person may bypass the interest list and begin the enrollment process.

Personal Attendant Services (PAS)

People who meet the criteria for immediate or expedited intakes and need immediate service initiation may be given a bypass code and go to the top of the interest list. People in the following programs may be considered for the criteria:

• Family Care;
• STAR+PLUS Home and Community Based Services (HCBS) people denied STAR+PLUS HCBS;
• people who have been denied Primary Home Care (PHC) due to loss of Medicaid; and
• people denied Community Attendant Services (CAS) due to denial of financial eligibility by Medicaid for the Elderly and People with Disabilities (MEPD) for reasons other than failure to cooperate or refusal to sign up for the Medicaid Estate Recovery Program (MERP).

The criteria are:

• the applicant has no available caregiver;
• has personal care needs that are not being met; and
• cannot go without personal care services for a full day; or
• the applicant needs personal care, and the need for services has increased during the five days before the service request or will increase during the five days following the service request. Review 2310, Criteria for Immediate or Expedited Responses to Service Requests, for more information.
• A person authorized for any Title XX service who is transferring to a new region is allowed to continue receiving that service.
• A person in a STAR+PLUS HCBS Residential Care facility who is denied STAR+PLUS HCBS may go to CCSE Residential Care. If a bed is not available, the person is placed on the Community Services Interest List (CSIL) and given a bypass code to move to the top of the interest list.

All people meeting bypass criteria are placed at the top of the specific program interest list. Additionally, the bypass criteria will now apply to people meeting the criteria who are no longer eligible for STAR+PLUS or STAR+PLUS HCBS or people denied financial eligibility for CAS. The regional director will decide if a person can be released immediately or remain on the interest list until funding is available. The decision must be documented.

2231.2 Bypass Criteria for Additional Services

Revision 24-5; Effective Nov. 1, 2024

People in the following circumstances may be given a bypass code and placed at the top of an interest list. The regional director decides if the person can be released immediately or will remain on the interest list until funding is available. The decision must be documented.

• Title XIX Day Activity and Health Services (DAHS) people denied Medicaid but who remain eligible for Title XX DAHS.
• People in a STAR+PLUS Home and Community Based Services (HCBS) Residential Care facility who are denied STAR+PLUS HBCS may go to Community Care Services Eligibility (CCSE) Residential Care. If a bed is not available, the person remains at the top of the interest list until a placement is available.
• People in a STAR+PLUS HCBS Adult Foster Care (AFC) who are denied STAR+PLUS HCBS may go to a CCSE AFC. If a bed is not available, the person is placed at the top of the interest list until a placement becomes available.
• People denied STAR+PLUS HCBS who had received additional services through STAR+PLUS HCBS, such as Home-Delivered Meals or Emergency Response Services, may be given a bypass code for those services.
• People authorized for any Title XX service that transfer to a new region are allowed to continue receiving that service.

2231.3 People Who May Not Bypass the Interest List

Revision 24-5; Effective Nov. 1, 2024

A person who has been denied Primary Home Care (PHC) because they do not need help with a personal care task should be placed on the Family Care (FC) interest list using the date of the PHC denial. They may not bypass the FC interest list.

People leaving a nursing facility are not eligible to bypass the interest list unless they meet the criteria for immediate or expedited as listed in 2231.1, Individuals Who May Receive Services with Regional Director Approval.

For people who have a temporary loss of categorical status or financial eligibility, follow the procedures in 3441, Loss of Categorical Status or Financial Eligibility, and 3441.1, Procedures Pending Reinstatement.

2231.4 Bypass Approval

Revision 24-5; Effective Nov. 1, 2024

The final decision on if a person is approved to bypass the interest list is made by the regional director or their designee rather than the regional budget officer or the contract manager. Releasing a name from the interest list and offering services to a person remains subject to available funding. 

2232 The Community Services Interest List System

Revision 24-3; Effective July 1, 2024

Interest lists for community care services are registered on the Community Services Interest List (CSIL) system.

Initial requests for services are documented using Form 2110, Community Care Intake, in the Long Term Care Service Intake (NTK) system, regardless  if funds for the requested service are available. If the person needs a service that is currently unavailable, use the interface on the NTK system or enter the person on CSIL. Complete and send the person:

• Form 2111, Interest List Notification; and
• Appendix XXXV, Long Term Services and Supports.

Only people who live in the state of Texas may be placed on an interest list for Texas Health and Human Services Commission (HHSC) community services. An out-of-state address can be used as a contact if the power of attorney, guardian or legally authorized representative is living out of state.

Information provided by the person for the interest list must include a Texas address as the contact location for the person requesting services. Exceptions may be made for people who are temporarily out of the state due to military assignments.

Exceptions involving military members and military family members, as described in 2230, Interest List Procedures, apply when:

• the applicant is a military family member living outside of Texas:
  • while the military member is on active duty; or
  • for less than one year after the former military member’s active duty ends; or
• the applicant declines the offer of a Community Services program with an interest list and the applicant is a military family member living outside of Texas:
  • while the military member is on active duty; or
  • for less than one year after the former military member's active duty ends.

If the caseworker is making a home visit to assess the person for other services, it is preferable for the caseworker to help complete appropriate application forms at that time. If not, this task may be accomplished by mail. If Form 2111 and Appendix XXXV are mailed, they must be sent within two workdays of intake. Forms being filled out in person at the time of the home visit must be completed within the time frames as indicated in 2320, Case Worker Response, as determined by intake priority.

Within five workdays of intake, staff enter all relevant data into the CSIL. Staff may choose to use Form 2113, Community Services Interest List Registration and Follow-Up, to manually record interest list information to be data entered. Although use of Form 2113 is not mandatory, regional staff are responsible for entering all applicable data fields it contains into the CSIL.

Staff may not perform functional or financial determinations at the time the person is being added to the interest list, even if staff are not using the determination to screen the applicant off the interest list. If a person insists that they be assessed for eligibility immediately, even though staff have assured them that no funds are currently available, staff are required to do so. This action is considered an application, not an interest list case. All notification and civil rights procedures apply.

People on an interest list are contacted annually to confirm that they wish to stay on the list. Form 2247, Interest List Contact Letter, is mailed to the person.

If a person does not respond and no update is made to the annual contact date in CSIL within 120 days past the annual contact due date, CSIL automatically updates the person’s record as inactive. An annual contact is no longer required for people in an inactive status. A person with a status of inactive will not lose their place on the interest list. If or when the CSIL persons record is updated with a current contact date, the record will automatically go back into an active status.

The CSIL must also be updated within five workdays of the caseworker’s determination and the date that a completed Form 2065-A, Notification of Community Care Services, is mailed or given to the person. Within five workdays of the case action, the caseworker records if the case was certified, application denied or closed without application. If the case was closed or denied, the reason for closure or denial must be indicated.

Review Appendix XXV, Community Services Interest List (CSIL) Closure Code User's Guide, or the CSIL User’s Guide found on the intranet and for staff use only.

2240 Reserved for Future Use

Revision 24-3; Effective July 1, 2024

2241 Supervisor Responsibilities

Revision 24-5; Effective Nov. 1, 2024

CCSE unit supervisors ensure that their units have procedures for:

• receiving service requests;
• mailing applications to requesters of service, when appropriate; calling requesters to ensure that applications were received; and
• instructing applicants, their families or both about completing applications;
• assigning service requests to appropriate caseworkers within required time frames;
• notifying caseworkers about applicants who may need help completing applications, when appropriate;
• ensuring that the intake priority is accurate and reassigning the response category if documentation shows the need; and
• monitoring and tracking requests for service, beginning with the date the request is received or assigned.

2242 Caseworker Responsibilities

Revision 24-5; Effective Nov. 1, 2024

CCSE caseworkers are responsible for the following:

• establishing a date for a home visit by calling a person when feasible;
• determining if the applicant is categorically eligible through Texas Integrated Eligibility Redesign System (TIERS) and printing verification if eligible;
• mailing an application to the non-categorically eligible applicant who requires a routine response to their service request if the applicant can complete the form or has help available;
• informing an applicant about the financial documentation, if any, that must be available at the time of the visit, such as verification needed when the applicant applies for Community Attendant Services (CAS);
• requesting that a person with knowledge of the person's financial affairs be available at the time of the visit, if possible and appropriate;
• requesting that the person's caregiver be present at the time of the visit, if possible;
• mailing the appropriate letter; and
• changing the intake priority if more information warrants. Document any changes made to the intake priority.

2243 Conflicts of Interest

Revision 24-3; Effective July 1, 2024

Texas Health and Human Services Commission (HHSC) staff control and direct significant amounts of public funds and must avoid the appearance of impropriety or conflict of interest. This applies to the awarding of Community Care Services Eligibility (CCSE) benefits and determining how these benefits are provided.

HHSC staff must not help a person receive CCSE benefits if the person is a relative either by blood or marriage, a roommate, dating companion, supervisor or someone under the person's supervision. Staff may not determine or redetermine eligibility, need for CCSE services or the amount of service a person may receive. HHSC staff may provide anyone with an application for services and inform them how and where to apply. It is also permissible to help any person gather documents needed to verify eligibility and the need for services. Staff must refrain from performing any other role in determining eligibility for CCSE services.

Caseworkers must consult with their supervisors if the person is a friend or an acquaintance. Generally, staff should not work on cases or applications involving these people, but the degree and nature of the relationship should be considered.

If staff have a relative either by blood or marriage, a roommate, dating companion or close friend who owns or is employed by a provider that contracts with HHSC to provide CCSE services, they must not demonstrate any special consideration toward that provider. Referrals of people to a provider must be based strictly on the person’s preference and the person's need for the service provided. In addition, instructions or lack of instructions to the provider about service delivery must be based solely on the person's needs and HHSC policy.

If a staff member suspects that a conflict exists, use intranet Form 2115 Conflict of Interest Notification, to notify the supervisor that a conflict of interest may exist that could result in an unethical or biased business relationship. The supervisor will record on the Supervisory Response section what action, if any, may be necessary and return the signed and dated form to the sender.

All CCSE staff are required to complete Form 2115 regardless of potential conflict of interest when:

• hired;
• the annual performance review occurs;
• transferring between units or programs; and
• assigned to another supervisor.

The form is also used to notify the first-line supervisor if a potential conflict of interest involves provider employees, people, even if staff are not involved in the eligibility determination for the applicant or person. Staff must complete Form 2115 if the potential conflict involves a person who is:

• living in their home;
• a dating companion;
• their supervisor;
• a relative; or
• reporting directly to them.

2310 Criteria for Immediate or Expedited Responses to Service Requests

Revision 24-5; Effective Nov. 1, 2024

A person requires an immediate response to their service request if they:

• have no available caregiver;
• have personal care needs that are not being met; and
• are unable to do without personal care services for a full day.

The following list gives examples of situations requiring immediate response. It is not intended to be all-inclusive.

The person:

• is totally bedridden or is unable to transfer from bed to chair without help;
• cannot manage toileting tasks without personal assistance; or
• is in danger of not receiving daily nourishment because of their need for total assistance in meal preparation or feeding.

A person requires an expedited response to their service request if they need personal care, they have no available caregiver, and their need for services has increased during the five days before the service request or will increase during the five calendar days following the service request. Example, the person:

• is being or has been released from a hospital or nursing home within five calendar days of the request and has no available caregiver to provide necessary care;
• is experiencing or recovering from a major illness and has no available caregiver; or
• loses their caregiver within five calendar days of the request and has no available substitute.

All people with AIDS or HIV infection requesting CCSE services should be carefully screened to determine if an immediate or expedited response is needed. CCSE regional nurses can provide consultation if needed. People with AIDS or HIV infection are often very ill and may need services initiated as soon as possible. Intake screeners and CCSE caseworkers must follow the procedures for immediate or expedited responses for all persons with AIDS or HIV infection who meet the criteria.

2320 Caseworker Response

Revision 25-2; Effective March 31, 2025

Respond to requests for Community Care Services Eligibility (CCSE) services per the following program standards:

If the person with AIDS or HIV infection does not need an immediate or expedited response at intake, the caseworker should closely monitor the situation during the routine referral process.

If the applicant's health condition suddenly deteriorates, make every effort to get services for the person as soon as possible.

After talking with the applicant or family, the caseworker may alter the urgency of the request, if the change is made before the deadline for the intake priority.

The caseworker may contact the applicant after the period specified above if the:

• intake states that the applicant or family requests a delay in the visit and the visit is made on the date requested; or
• caseworker makes two attempted contacts within the designated period.
  • One attempted contact must be tried face-to-face contact such as a home, hospital, or nursing home visit with the applicant or the authorized representative, referral source or other knowledgeable party if the applicant is unable to respond to the assessment questions.
  • The other attempted contact must be either another tried face-to-face contact or an attempted phone contact with the applicant, their authorized representative, referral source or other knowledgeable party, if the intake does not identify an authorized representative for the applicant.

If the caseworker contacts the applicant to schedule an appointment and the applicant refuses and states they do not want services, the caseworker must close the intake in the Intake (NTK) system. The caseworker may use the denial codes from the Community Services Interest List (CSIL) system in the comments in NTK. No entries in the Service Authorization System Online (SASO) are required and Form 2065-A, Notification of Community Care Services, is not sent.

The caseworker should make every effort to ensure that the initial visit is conducted as close as possible to the date of the case assignment to the caseworker. For service control purposes, this standard should be measured by comparing the date and time of the case assignment on Form 2110, Community Care Intake, to that on Form 2060, Needs Assessment Questionnaire and Task or Hour Guide. Use the date of the initial assessment contact for Day Activity and Health Services (DAHS) only cases. If the intake priority for all except DAHS is not checked or information indicating priority level is not contained in case documentation, it is assumed to be immediate.

Although 14-calendar days is allowed for a routine referral, timelines cannot be used as a justification to delay contact with the person. If the two attempted contacts both occur near the end of the 14-calendar day period, the caseworker or supervisor may choose to call a timeliness error if a justifiable reason for delay is not documented in the case record.

Example: A case assignment for services is received March 1. The caseworker makes the first attempted contact on March 11, and the second on March 14. To meet the program standard relating to timeliness of initial contact, the caseworker must document why the delay could not have been avoided.

2330 Scheduling the Initial Interview

Revision 26-2; Effective June 1, 2026

The applicant is entitled to a face-to-face interview during the eligibility determination for CCSE services.

Determining eligibility for CCSE services typically begins with a face-to-face assessment of the person, preferably in the home. Home visits are required for all CCSE applications, except for applications requesting Emergency Response Services, Home-Delivered Meals or Day Activity and Health Services. Initial home visits for any one of these three services are required at the applicant's request. A face-to-face home visit is required if, during the phone interview, it is determined attendant care is needed or requested, per 2431, Form 2060, Part A, Functional Assessment, and 4651, Assessing the Person’s Needs.

Caseworkers must make at least two attempts to contact a person before closing an intake. These two contacts should not be on the same day. The caseworker may schedule the appointment by phone or use appointment letter Form 2068, Application Redetermination or Monitoring for Community Care Services. When feasible, ask the person's current caregiver to be present during the assessment.

Schedule home visits for a time that is convenient for the applicant. If the appointment cannot be kept for any reason, the caseworker must notify the applicant or authorized representative in advance that the appointment will be rescheduled. Do not visit the applicant without informing the person before the visit.

If the person is not home for the scheduled appointment, the caseworker should leave a business card or letter with the relevant office and caseworker contact information for the person. The caseworker should make a second attempt to contact the person. The other attempt may be by phone or by home visit. If either attempt is unsuccessful, the caseworker may close the intake. The caseworker cannot close the intake until at least the second business day after the second contact attempt. The caseworker needs to give the person time to contact them.

Example 1: Intake is assigned to the caseworker on Friday, March 2. On Monday, March 5, the caseworker mails an appointment letter to meet on the following Monday, March 12. The caseworker makes the home visit, but no one is home. The caseworker leaves a letter on the door for the person with the office and caseworker information. The caseworker follows up by attempting to contact the person by phone on Wednesday, March 14, but was unsuccessful. The caseworker was unable to reach the person or leave a message because the person’s number does not have voicemail. If the person does not respond, the caseworker may close the intake since they made two attempts to contact the person. The caseworker may close the intake on the second business day after the second attempt or Friday, March 16.

Example 2: Intake is assigned to the caseworker on Friday, March 2. On Monday, March 5, the caseworker calls and reaches the person’s daughter, whose phone number is the only number listed on the intake. The daughter states she has a power of attorney (POA) and lives with her mother, who is the person who needs services. The daughter agrees to a home visit on Friday, March 9. The caseworker verifies the address and asks if any other phone numbers need to be listed. The daughter verifies the address. The caseworker makes the home visit, but no one is at home. The caseworker leaves a business card with their contact information on the door for the person and her daughter. The caseworker made two attempted contacts, one by phone to set the appointment and one with the home visit. If the person has not responded, the caseworker may close the intake on Tuesday, March 13, which is the second business day after the second attempt to contact the person.

When a caseworker contacts an applicant to schedule a home visit and the person states they have a contagious illness, such as influenza, the caseworker must document the contact, reason for the delay and include the stated illness. The caseworker should try to schedule a future date for the visit when the applicant thinks they will be better. If unable to schedule the visit for a future date, the caseworker must contact the applicant at least weekly until the home visit can be made. Each contact must be documented. This documentation is considered an acceptable reason for delaying a required home visit.

A face-to-face visit with a person in a nursing home, hospital, prison or jail facility is acceptable. Such visits, however, do not allow the caseworker to assess the person in their home environment or to assess family resources and how they function at home. If the initial visit and eligibility determination must be done in a location other than the person's home and in-home services are subsequently initiated, conduct a home visit within 30 calendar days after service initiation. Make any necessary revisions to the service plan per 2663, Reassessment of Functional Need. Document the date of the home visit.

A person is not required to submit an application form if:

• they already receive services from HHSC, or 
• the Social Security Administration has already verified that the person is financially eligible for Supplemental Security Income (SSI).

A person who is not receiving services from HHSC, not receiving SSI, or who needs a financial eligibility determination from Medicaid for the Elderly and People with Disabilities (MEPD) must complete Form H1200, Application for Assistance – Your Texas Benefits.

The form may be mailed if the applicant can complete it or has help available. If the applicant is not capable of completing the form, the caseworker must provide the form and help the applicant complete it at the first interview. If the form has been mailed to the applicant, the caseworker must review the form for completion at the first interview and, if necessary, help the applicant complete it.

The official date of application is the date HHSC staff receive a completed, signed and dated Application for Assistance. The application date on the Service Authorization System screen is the date of:

• receipt of the application, as defined above; or
• the initial home visit, for categorically eligible applicants for whom an application form is not required.

Related Policy

26 Texas Administrative Code Section 271.151(b)
Categorical Eligibility, 2341.3 
Income and Income Eligibles, 3310

2331 Information and Referral (I&R)

Revision 24-5; Effective Nov. 1, 2024

Refer the person to the appropriate agency or community resource if it is determined during the initial interview that they could use services from other agencies in the community. Thoroughly discuss the referral with them and their family if they are present. Give complete information about Community Care Services Eligibility (CCSE) services and about any other Texas Health and Human Services Commission (HHSC) services. For example, the Supplemental Nutrition Assistance Program (SNAP) or the Qualified Medicare Beneficiary program that might be helpful. Review Appendix XV, Services Available from Other State Agencies.

Always refer an applicant or person to the Social Security Administration if the person appears eligible for Supplemental Security Income (SSI) but does not receive SSI. Consult with Medicaid for the Elderly and People with Disabilities (MEPD) staff if there are questions about SSI eligibility.

When referring a person to other agencies or other HHSC services, fully inform them about where they must go to apply. Help set up their appointment, if necessary. Provide the office address, phone number, name of the correct person to contact, and the appointment date and time, if known.

Provide I&R services to people regardless of their income. Do not register with the Service Authorization System Online (SASO) persons who receive only I&R services. Document I&R services as required by regional policy.

2332 Requests for Services from People Under 21

Revision 24-5; Effective Nov. 1, 2024

Children who have a medical need and meet other eligibility requirements may receive Community Attendant Services (CAS). The age requirements that apply to other community care programs do not apply to CAS. However, applicants under 21 must meet all other eligibility criteria, including medical, financial, functional and unmet need.

Once a request for services from a person under 21 is received, the caseworker must contact the regional nurse and arrange for a joint visit for the initial home visit assessment. The regional nurse helps screen the person for medical need, determines if there are skilled tasks that the personal attendant cannot perform, and determines if the caregiver must be present in the home to perform skilled tasks or react to emergency medical situations while the personal attendant is in the home.

Review Appendix XXXIII, Requests for Services from Individuals Under 21 Years of Age, for more information.

2333 Applications

Revision 24-2; Effective June 1, 2024

An application for services was made if any one of the following occurs:

• a face-to-face home visit for an intake or interest list release that has occurred;
• the caseworker has completed or begun to complete any part of Form 2060, Needs Assessment Questionnaire and Task and Hour Guide; or
• Form H1200, Application for Assistance-Your Texas Benefits, was completed and received by HHSC.

Once an application has begun, the caseworker must record the disposition of the application, including denials, in the Service Authorization System Online (SASO).

Examples

Example 1- Request for Services Only: A hospital social worker contacts HHSC for someone who is being discharged the following day. The social worker notes that the person lives alone and that they will need personal attendant services (PAS) because of their condition. In response to the social worker's call, an intake specialist contacts the person and they state that their daughter will be living with them during the weeks after their release from the hospital. The daughter will be able to provide all of their needs. They state that they will call HHSC if PAS is needed later.

This is not an intake. It is an example of an appropriately screened request for services when it is determined CCSE services are not currently needed. Although some information may have been recorded on Form 2110, Community Care Intake, in the Intake (NTK) system, a caseworker was not assigned to the case. There is no need to send Form 2065-A, Notification of Community Care Services. No entries in SASO are required.

Example 2 - Intake Only for Title XX services that do not require a home visit: A person contacts HHSC requesting Home-Delivered Meals (HDM). The intake specialist enters the information into the Community Services Intake List (CSIL) and completes the Form 2110 information in the Intake (NTK) system if the person is not currently receiving CCSE services.  When funds are available, the Title XX request is assigned to a caseworker. When the caseworker calls to set up an appointment, the person states they have changed their mind and do not want CCSE services. The caseworker records the correct denial code in the Community Services Interest List (CSIL) and if needed, closes the request in the Intake (NTK) system. There is no need to send Form 2065-A. No entries in SASO are required.

Example 3- Application: A person contacts HHSC and requests Community Attendant Services (CAS). The caseworker schedules a face-to-face home visit and upon arriving at the person’s home, the person states they are moving out of state and they do not need services. Because a face-to-face home visit was made, this is considered an application and the application denial must be entered in SASO. Form 2065-A is sent to the applicant.

2333.1 Required SASO Entries for Applications Withdrawn Early in the Process

Revision 26-1; Effective March 1, 2026

All applications, including denials, must be entered in the Service Authorization System Online (SASO) within 30 calendar days of:

• the face-to-face home visit date;
• receipt of the Form H1200, Application for Assistance-Your Texas Benefits; or
• the caseworker has completed or has begun to complete any part of Form 2060, Needs Assessment Questionnaire, and Task and Hour Guide.

Review 2611, Processing Time Frames, for more information.

If a person does not have an existing individual number in Texas Integrated Eligibility Redesign System (TIERS), the Create New Client function must be used.

Complete the required records in SASO: 

• Address,
• Phone,
• Other Information,
• Case Ownership. 

Select the program or programs the person is applying for on the Service Request screen. 

Complete the Financial Wizard based on information reported on Form H1200, if received. If an application is being denied because functional eligibility and financial eligibility has not been determined, or Medicaid Eligibility for Persons with Disabilities (MEPD) has denied the CAS application, the caseworker may enter zeros in the financial information to proceed to the Functional Wizard.

Complete the Functional Wizard based on information obtained at the initial assessment.  Enter the intake date, assignment date, application denied date and select reason for denial on the interview screen. Explain the reason for denial by documenting in the Comment Section of the automated Form 2060. Click next until you get to the Eligibility Determination Screen.

The Eligibility Determination Window will appear with a pop-up box that shows a list of errors. From this window click Generate, Close and Submit.

Complete Form 2065-A, Notification of Community Care Services in SASO within two business days to notify person of the denial. Review Form 2065-A Instructions, Attachment A and 2810, Individual Notification Procedures.

2340 The Initial Interview and Application Process

Revision 24-2; Effective June 1, 2024

During the initial interview, the caseworker:

• explores the applicant's needs and which services can meet those needs, including services available from other agencies;
• helps the applicant to complete Form H1200, Application for Assistance-Your Texas Benefits, when the applicant is not categorically eligible;
• screens the applicant for the Community Attendant Services (CAS) program, if requesting attendant services;
• completes Form 2060, Needs Assessment Questionnaire and Task and Hour Guide, including assessing the applicant's functional eligibility relative to the performance of activities of daily living and assessing the applicant's home, social and environmental supports and resources;
• presents Appendix XXXV, Long Term Services and Supports;
• reviews and explains Form 2307, Rights and Responsibilities, including all corresponding attachments;
• offers to help the applicant register to vote;
• reviews and explains the available service delivery options and completes the required documentation explained in section 6000, Service Delivery Options; and
• presents Form 8001, Medicaid Estate Recovery Program Receipt Acknowledgement and asks the person to sign the form, if the person is requesting Community Attendant Services (CAS). 

Review section 2347, Texas Medicaid Recovery Program, for additional information.

If the applicant can only sign documents with an "X," the caseworker completes the required documentation and then dates and initials the entry.

The caseworker must be alert for signs of abuse, neglect or exploitation when assessing people for CCSE services. Anyone with reason to believe a person who is elderly or a person with a disability is being abused, neglected or exploited must report this information to the Department of Family and Protective Services (DFPS) Adult Protective Services (APS).  Immediately notify APS of any reports received that indicate a person who is elderly or a person with a disability has been abused, neglected or exploited.

If a person who is applying for or is receiving CCSE services was referred to APS in the past and it is possible another referral may be needed now for the same problems, contact APS to discuss the situation before a formal referral is made. Document the APS response in the CCSE case record. Review Appendix XV-E, Department of Family and Protective Services (DFPS), for more information.

2341 Financial Application Process

Revision 26-1; Effective March 1, 2026

Applicants or their representatives must sign a Form H1200, Application for Assistance – Your Texas Benefits when applying for services if they are not categorically eligible. Non-Medicaid applicants or their representatives who apply for retroactive reimbursement for Medicaid-covered attendant services must also sign Form H1200. The date of application is the date HHSC receives the signed application. This date must be entered in the Financial Wizard in Service Authorization System Online (SASO). Applicants must provide correct information about income and resources.

Non-Medicaid applicants or their representatives who apply for Medicaid-covered attendant services may be reimbursed for services provided for up to three months before the month of receiving a completed, signed and dated application.

If an application is denied for any reason, the previously completed application form is valid for 90 calendar days after the date of denial. Get a written, dated and signed statement of request to reapply from the applicant or authorized representative. The statement must be sent to Medicaid for the Elderly and People with Disabilities (MEPD) before the close of business on the second business day. Documentation must show changes that have occurred since the original application date.

The caseworker submits the written statement and the documents with Form H1746-A, MEPD Referral Cover Sheet, with the application box checked. The caseworker must clearly note on Form H1746-A that the applicant is requesting to reapply for Community Attendant Services (CAS). The caseworker includes all identifying information on Form H1746-A, and any other information that will help identify the original application. The caseworker faxes Form H1746-A and documents to the Austin Document Processing Center.

The caseworker will also be able to use Form H1200, Application for Assistance – Your Texas Benefits, on file for up to 90 calendar days following the denial date of Form 2065-A, Notification of Community Care Services. The caseworker may also use Form 2060, Needs Assessment Questionnaire and Task or Hour Guide, the other forms signed at the initial home visit and verifications on file. The caseworker does not need to make another home visit but must review Form H1200 and Form 2060 with the applicant and document any changes that have occurred since the first visit. The caseworker needs to follow appropriate time frames for annual reassessments. The annual reassessment is still due within 12 months of the initial home visit.

Related Policy

26 Texas Administrative Code (TAC) Section 271.151(c)
TAC Section 271.151(e)

2341.1 Application for Assistance Form

Revision 24-1; Effective March 1, 2024

People applying for services without categorical eligibility status apply for Community Care Services Eligibility (CCSE) services by completing Form H1200, Application for Assistance – Your Texas Benefits.

Use Form H1200 for people who are:

• not Medicaid recipients and apply or appear to be eligible for community Attendant Services (CAS); or
• non-Medicaid applicants who are not categorically eligible and who apply or appear to be eligible for:
  • Title XX CCSE services; or
  • Qualified Medicare Beneficiaries (QMB) or Specified Low-Income Medicare Beneficiaries (SLMB).

An application is incomplete until it contains the person’s signature. If unable to sign, it is acceptable to allow the person to make an "X," along with two witnesses' signatures. Unless no other option is available, the case worker should not be one of the witnesses.

If Form H1200 is being sent to Medicaid for the Elderly and People with Disabilities (MEPD), the signature must be on the form. Unsigned applications will be returned to the sender. HHSC staff must ensure applications are signed before referring to MEPD. If MEPD receives an unsigned application from HHSC with either Form H1746-A, MEPD Referral Cover Sheet, or Form 2067, Case Information, MEPD returns the application to HHSC with an annotation on the cover form (Form 2067 or Form H1746-A) that the application is unsigned and must be signed before HHSC can establish a file date. Once HHSC staff receive an unsigned application from MEPD, they must coordinate with the person to get the application signed and returned to MEPD for processing.

Sending unsigned applications delays the MEPD and HHSC eligibility processes and could adversely affect service delivery to people.

2341.2 Application for Assistance Form Completion and Receipt Date

Revision 25-4; Effective Sept. 1, 2025

Form H1200, Application for Assistance – Your Texas Benefits, may be mailed if the applicant can complete it or has help available. If the applicant cannot complete the form, the caseworker must provide and help the applicant complete it at the initial interview.

If Form H1200 has been mailed to the applicant, the caseworker must, at the initial interview, review the form for completion and help the applicant complete the form, if necessary.

Make sure the applicant completes the entire application, signs and dates it. The applicant understands the penalties for fraud if they deliberately give false information. Do not make any changes to Form H1200 after the applicant signs it.

For applicants or people who require a Medical Assistance Only (MAO) determination be sent to Medicaid for the Elderly and People with Disabilities (MEPD), the caseworker must help the applicant or person complete the application and provide the most complete packet possible to MEPD. The caseworker should make sure the following items are included to help the financial eligibility process:

• bank accounts – bank name, account number and balance;
• award letters that show the amount and frequency of income payments;
• life insurance policy – the company name, policy number, face value or copy of the policy;
• a signed and dated Form H0003, Agreement to Release Your Facts;
• confirmation that Medicaid Estate Recovery Program and Appendix XXXV, Long Term Services and Supports, were shared with the applicant by checking the appropriate boxes on Form H1746-A, MEPD Referral Cover Sheet;
• preneed funeral plans – the name of company, policy or plan number, and copy of the preneed agreement;
• correct up-to-date phone numbers; and
• power of attorney or guardianship – a copy of the legal document.

While it may not be possible to get everything on the list, the caseworker should gather all available information to prevent the applicant from a delay in certification. The caseworker should explain to the applicant that failure to submit the required documentation to MEPD could delay the completion of the application or cause the application to be denied.

When the caseworker receives a signed and dated Form H1200 at the home visit or it is mailed or hand delivered to a Texas Health and Human Services Commission (HHSC) office, the date of receipt becomes the official date of application.

If Form H1200 has not been returned by the 30th calendar day from the initial home visit or initial assessment, the caseworker may deny the application. The caseworker sends Form 2065-A, Notification of Community Care Services, with Rule Reference 26 Texas Administrative Code Section 271.151(c): Applicants or their representatives applying for services provided with regard to income must sign an application for assistance form. In the comments section, the caseworker enters: HHSC is unable to make an eligibility decision within 30 calendar days due to your failure to furnish information. The caseworker must document all contacts.

When an income-eligible person is receiving services with a form less than one year old, and their spouse applies after them, the eligible person’s form may be used for their spouse. Review Form H1200 to make sure the information is still valid, have the spouse sign and date it for the current application, and complete a new eligibility determination.

2341.3 Categorical Eligibility

Revision 24-3; Effective July 1, 2024

If Social Security or another program within the Texas Health and Human Services Commission (HHSC) has already made a financial determination for the applicant, the applicant may be considered categorically eligible. The applicant is categorically eligible if receiving:

• Supplemental Security Income;
• Temporary Assistance for Needy Families;
• Supplemental Nutrition Assistance Program;
• Medicaid;
• Medicaid Buy-In (MBI) benefits*;
• Qualifying Individual (QI) benefits;
• Specified Low-Income Medicare Beneficiary (SLMB) benefits;
• Qualified Medicare Beneficiary (QMB) benefits; or
• other Community Care Services Eligibility (CCSE) services.

*Note: Medicaid Buy-In benefits provide categorical eligibility only for the following programs:

• All Long-Term Services and Supports Title XX programs
• Day Activity and Health Services Title XIX
• Primary Home Care
• Texas Home Living waiver program

For categorically eligible applicants, the process is streamlined. Completion of the Application for Assistance form is not required. Instead, the date of the initial contact with the person is considered the date of application. This simplification is designed to make the process more efficient and less burdensome for the applicant.

Review section 7110, TIERS Inquiries, for complete information on how existing coverage affects eligibility for CCSE services.

2341.3.1 Effect of QI Benefits on Eligibility for Community Care Services

Revision 24-5; Effective Nov. 1, 2024

The Qualifying Individuals (QI) program was created by Public Law 105-33 as part of the Balanced Budget Act of 1997. The legislation specifies that QI recipients cannot be eligible under any other Title XIX-funded program and simultaneously receive QI benefits. Therefore, applicants and people receiving QI benefits do not qualify for Primary Home Care (PHC), Community Attendant Services (CAS), or Title XIX Day Activity and Health Services (DAHS). QI recipients are eligible to receive Title XX Family Care (FC), Title XX DAHS, or both, provided all other eligibility criteria are met.

Identification of QI Coverage

At the time of application for Title XIX services and at each annual reassessment, caseworkers must check the Texas Integrated Eligibility Redesign System (TIERS) to determine if the person is receiving QI services. TIERS designates QI coverage as Type Program (TP) of Assistance TP-26.

Procedure for Applicants

If an applicant specifically requests PHC, CAS or DAHS, explain that people may not receive QI while receiving any other Title XIX-funded service. Inform the person that they can receive Title XX FC or Title XX DAHS at the same service levels. Receipt of QI services does not prevent applicants from being placed on any interest list.

Procedure for Ongoing People

Once it is known that a person receiving a Title XIX Community Care Services Eligibility (CCSE) service CAS, PHC, or Title XIX DAHS has been certified for QI benefits, the caseworker first determines if enrollment in Title XX FC or DAHS is open or if an interest list exists for the desired service. If no interest list exists, process the request for the desired service. If it is determined that the person must be placed on a Title XX FC or DAHS interest list, the caseworker must contact the person to give them the choice of service they want to continue QI or Title XIX CCSE service.

The caseworker's next actions will depend on the person's decision:

• If the person elects to continue receiving the Title XIX CCSE service, explain that this requires that their QI benefits be denied. Send Form 2067, Case Information, to the Medicaid for the Elderly and People with Disabilities (MEPD) specialist to let MEPD know about the person's decision.
• If the person decides to transfer to a Title XX service to keep their QI benefits, grant that service if regional budgetary conditions allow without placing them on the interest list. Otherwise, the person should be placed at the top of the interest list. Title XIX service cannot remain open while the person waits for available Title XX funding.
• Follow up with written notification using Form 2065-A, Notification of Community Care Services.

2341.4 Refusal to Cooperate with the Application Process

Revision 24-1; Effective March 1, 2024

If the applicant refuses to sign Form H1200, Application for Assistance – Your Texas Benefits, or otherwise refuses to participate in the assessment process, do not proceed with the application process. Advise the applicant that they will receive a notice of ineligibility in the mail. Send the applicant Form 2065-A, Notification of Community Care Services. Use Code 17, "You failed to provide the necessary information."

2341.5 Retroactive Payment Process

Revision 24-5; Effective Nov. 1, 2024

The retroactive payment process is an option that a person or the provider may use if the person has an immediate need for help with personal care task(s) pending the Texas Health and Human Services Commission's Medicaid eligibility decision. Review section 2348, Retroactive Payments.

2342 Screening for Personal Attendant Services

Revision 25-4; Effective Sept. 1, 2025
 
Program Standard: Staff must screen all applicants and recipients for potential eligibility for Primary Home Care (PHC) and Community Attendant Services (CAS) before referring them to Family Care (FC) or continuing with authorization for FC.

Screening Initial Applicants

Before the initial interview, determine if the applicant currently receives Medicaid. If the person is active on Medicaid, explore eligibility for PHC using the additional screening criteria to determine if a referral to PHC is appropriate.

If the person's income and resources appear to be within the Supplemental Security Income (SSI) limits and they appear to have a medical need for help with personal care, refer them to the Social Security Administration (SSA) for an SSI application. However, staff should continue the referral for CAS even if the applicant refuses to apply for SSI.

If the person does not receive Medicaid and their income and resources are above SSI limits, complete Form H1200, Application for Assistance – Your Texas Benefits, during the interview or review the application form mailed to the applicant for completion. Help the applicant complete the form and get all available required verifications.

If the person cannot complete the application during the interview, explain that it is essential to return the form and any additional verification documents as soon as possible. Also, explain their eligibility for attendant services cannot be determined until the form is received.

All initial applications for Personal Attendant Services who do not have Medicaid and who have personal care tasks purchased must be referred to MEPD to determine eligibility for CAS. If the applicant receives Qualifying Individuals (QI) benefits, review 2341.3.1, Effect of QI Benefits on Eligibility for Community Care Services.

Fax the completed application and verification documents and Form H1746-A, MEPD Referral Cover Sheet, to the Austin Document Processing Center (DPC) within two business days.

Screening Ongoing FC Cases for PHC or CAS

If a person or provider reports interim changes between annual reassessments, apply the screening exception criteria at the next annual review.

Review the screening exception criteria to see if the person’s circumstances have changed at each annual functional reassessment of FC. Review 2342.3 Exception Criteria for Referrals to PHC and CAS. If exception criteria still applies, document the specific criteria that is applicable.

Example: A person was placed on FC because of no personal care tasks, the annual reassessment is being completed over the phone, and the person now requires a personal care task. Staff must refer the person to CAS or PHC and complete the home visit within 14 calendar days of the annual functional reassessment.

Example: A person was placed on FC because they did not have a practitioner, their practitioner refused to sign Form 3052, Practitioner’s Statement of Medical Need, or getting a practitioner's statement was unsuccessful. Caseworker must ask the person if this situation has changed.    

CAS – A referral to MEPD must be sent within two business days of the home visit for the annual functional reassessment.

PHC—If enrolling the person in STAR+PLUS is not mandatory, the transfer to PHC must be completed within 14 calendar days. If enrolling the person in STAR+PLUS is mandatory, leave the person on FC but start the process for the person’s enrollment in STAR+PLUS.

Financial eligibility must be redetermined for FC within 24 months of the last eligibility determination.

Example: If MEPD previously determined the person was ineligible for CAS, explore the reason CAS had been denied in the past to determine if anything has changed. If it appears the person now meets CAS requirements, staff must help the person complete a new Form H1200, Application for Assistance – Your Texas Benefits, and get verification of income and resources to send to MEPD.

Related Policy

Timely Referral to MEPD, 2342.2
Exceptions to Verification Requirements, 3422
Transition Between HHSC and STAR+PLUS, 6430
Income and Resource Limits, Appendix XI
Family Care Eligibility, 4420

2342.1 Receipt Date of the Application Form

Revision 24-5; Effective Nov. 1, 2024

The date of the official application is the day the application form is received by the caseworker at a home visit or received by mail or hand delivered to a Texas Health and Human Services Commission office.

Review 2333, Applications for a list of acceptable applications.

If the caseworker receives the application form during the home visit, the caseworker enters the date in the Date Form Received box at the top of the form.

2342.2 Timely Referral to MEPD

Revision 26-2; Effective June 1, 2026

Before the initial home visit, staff must check TIERS to determine if the applicant has an active record. If there is no active record, consider the person a new applicant. A new applicant is a person who is not currently authorized to receive services in TIERS.

Consider the application complete with a name, address and signature. A person does not have to fill out the entire application to be considered valid. The date the application form is received with the name, address and signature is considered day zero.

New Applications

No later than the close of business on the second business day after a completed application form is received, staff must:

• fax the completed application and verification documents with Form H1746-A to the Austin Document Processing Center (DPC); and
• retain the original Form H1200, Application for Assistance – Your Texas Benefits, and a copy of the successful fax confirmation page in the case record. The original application form must be retained in the case record for three years after the case is denied or closed.

Prior Applications

If an active record of the applicant is found in TIERS, including current recipients requesting a program transfer, then no later than close of business on the second business day after receipt of the completed application form, CCSE staff must:

• fax the completed application and verification documents to the Austin DPC, using Form H1746-A as a cover sheet; and
• keep the original Form H1200, Application for Assistance – Your Texas Benefits in the case file. The original form must be kept for three years after the case is denied or closed. CCSE staff must also keep a copy of the successful fax transmittal confirmation in the case record.

Transmittal

All communication to MEPD must include Form H1746-A, MEPD Referral Cover Sheet.

Note: Form 2067, Case Information, is not an acceptable means of communication to MEPD staff.

If Form H1746-A is not completed correctly, an incorrect assignment to MEPD staff could result.

CCSE staff must follow the guidelines listed in the H1746-A form instructions or Appendix V, Guidelines for Completing Form H1746-A, MEPD Referral Cover Sheet, to make sure the correct assignment is made.

Related Policy

Application for Assistance Form, 2341.1
Medicaid Program Actions, Appendix XXXII
Guidelines for Completing Form H1746-A, MEPD Referral Cover Sheet, A

2342.3 Exception Criteria for Referrals to PHC or CAS

Revision 26-1; Effective March 1, 2026

The caseworker must screen all applicants and recipients for potential eligibility for Primary Home Care (PHC) and Community Attendant Services (CAS) before referring them to Family Care (FC) or continuing with authorization for FC. The caseworker applies the following exception criteria to decide if the person has a reason not to be referred for CAS or, if on Medicaid, would not be eligible for PHC.

To determine if the person is not appropriate for a referral to PHC or CAS, screen them for the following criteria:

• Does the person specifically state that they will accept care only from their spouse as the paid attendant, and the unmet need policy does not prevent this arrangement?
  • If yes, the person is referred for FC or placed on the FC Interest List and is not referred for CAS.
  • If no, continue the screening process.
• Does the person receive Qualifying Individual (QI) benefits?
  • If yes, explain the benefit choices. Review 2341.3.1, Effects of QI Benefits on Eligibility for Community Care Services.
  • If the person elects to keep the QI benefits, they may be referred for FC or placed on the FC Interest List.
  • If the person chooses to be referred to CAS, continue the screening process.

Other Criteria

Does the person:

• meet the citizenship requirements needed to establish eligibility for Medicaid-funded programs?
• need help with at least one personal care task?
• have a medical condition that causes a functional impairment when performing personal care tasks?
• have a medical diagnosis other than mental illness, intellectual disability or both?
• have a practitioner who will sign a statement that the person has a medical need for help with personal care tasks and other activities of daily living?

Does the person require at least six hours of service per week or meet exemptions listed in 4633, Functional Eligibility?

The caseworker makes a referral for PHC or CAS if the applicant answers Yes to all other criteria. The caseworker refers the person for FC or places the person on the FC Interest List if the person answers No to any one of the other criteria. The person is not referred for PHC or CAS.

Note: All initial applications for Personal Attendant Services who do not have Medicaid but do have personal care tasks purchased must be referred to MEPD to determine eligibility for CAS.

Placement on the FC Interest List

Assigned staff must use the original date of the request for services and enter all relevant data into the Community Services Interest List (CSIL) within five workdays of screening for CAS or PHC if FC enrollment is:

• open, and the person does not meet the screening criteria for CAS or PHC, or the caseworker will authorize FC while CAS financial eligibility is pending; or
• not open and the person does not meet the screening criteria for CAS or PHC.

The date the person called to request services is the original date of the request for services, which is listed on Form 2110, Community Services Intake.

FC Services Pending the CAS Eligibility Decision

If FC enrollment is open in a region, the caseworker assesses the person for FC. If eligible, the caseworker authorizes services while the CAS eligibility decision is pending from MEPD. If a person placed on the FC Interest List is released from the list, the caseworker must screen the person for CAS and refer to MEPD if screening criteria are met. The caseworker also assesses the person for FC and, if eligible, authorizes services while the CAS eligibility decision is pending.

If the person is found to be eligible for CAS, the caseworker follows the policy in 4652.3, Initial Referrals for Community Attendant Services, and negotiates a transfer from FC to CAS. The caseworker sends Form 2065-A, Notification of Community Care Services, noting the transfer of services. If the person is not eligible for CAS, the caseworker continues FC services unless the person was denied CAS for refusal to cooperate.

Refusal to Cooperate with MEPD

If the person is denied services for refusal to cooperate with the financial eligibility determination process, including refusal to furnish information or withdrawing the CAS application, the caseworker must follow up with the person to explore why they did not cooperate. If the person states they are unwilling to cooperate with the financial eligibility determination process, then the caseworker must tell the person their application for services is denied and they will be referred for CAS again if they reapply. The caseworker documents all contacts and sends Form 2065-A to the person, citing 26 TAC Section 271.69(a)(3) The caseworker includes the following statement in the Comments section: To be eligible for Family Care, you must be ineligible to receive attendant care services funded through Medicaid. Medicaid for the Elderly and People with Disabilities has notified HHSC you failed to provide the necessary information to determine eligibility for Medicaid-funded services. 

If the person requests to be placed on the FC Interest List, they may be placed on the interest list but must be told they will be referred to CAS when their name is released from the list.

If the person is receiving FC services pending the MEPD eligibility decision and refuses to cooperate with the financial eligibility determination process described above, the caseworker must deny FC services. The caseworker documents all contacts and sends Form 2065-A to the person citing 26 TAC Section 271.69(a)(3). The caseworker includes the following statement in the Comments section: To be eligible for Family Care, you must be ineligible to receive attendant care services funded through Medicaid. You failed to provide the necessary information to determine eligibility for Medicaid-funded services.

If the person states they cooperated and thought they submitted all requested information, the caseworker may check the Comments section in the Texas Integrated Eligibility Redesign System (TIERS). The caseworker may need to help the person get any missing requested documents.

The person can reapply for CAS for up to 90 calendar days from the date of the MEPD denial without completing a new Form H1200, Application for Assistance – Your Texas Benefits. The caseworker must get a written, dated and signed statement of request to reapply from the applicant or authorized representative to establish the date of application. The caseworker submits the written statement and the documentation with Form H1746-A, MEPD Referral Cover Sheet, marked Application. The caseworker must clearly note on Form H1746-A that the applicant is requesting to reapply for CAS. The caseworker includes all identifying information on Form H1746-A, and any other information that will help identify the original application. Fax Form H1746-A and documentation to the Austin Document Processing Center.

Applications Denied by MEPD

If a referral is sent to MEPD and the person is denied CAS eligibility for reasons other than refusal to cooperate with the financial eligibility determination process, the person remains eligible for FC or is placed on the FC Interest List. The assigned staff uses the original request date for services and enters the information into the CSIL when placing the person on the interest list.

If the person is receiving FC and is denied by MEPD for income or resources, the caseworker must review the reason for denial and make sure the person continues to meet financial eligibility requirements for Title XX. The FC case must be denied if the countable income or resources are over the Title XX limits. Refer to 3200, Resource Eligibility Criteria and 3300, Income Eligibility.

If the person who was denied CAS eligibility for reasons other than refusal to cooperate is released from the FC Interest List within 90 calendar days of the application date, the caseworker may use:

• Form H1200, Form 2060, Needs Assessment Questionnaire and Task or Hour Guide;
• the additional forms signed at the initial home visit; and
• verifications on file to determine eligibility for FC.

The caseworker:

• must establish that the person meets all financial eligibility requirements for Title XX services;
• does not need to do another home visit but must review Form H1200 and Form 2060 with the applicant and document any changes that have occurred since the first visit; and
• will need to follow appropriate time frames for annual reassessments. The annual reassessment are still due within 12 months of the initial home visit.

FC Annual Reassessments

Refer to 4447, Reassessment, for FC reassessment procedures.

2342.4 Spouse Attendant in Family Care Services

Revision 24-5; Effective Nov. 1, 2024

If a person states they will accept care only from their spouse, then the person may be assessed for Family Care services or placed on the Family Care interest list. They are not referred to Primary Home Care (PHC) or Community Attendant Services (CAS).

People on Medicaid may elect to receive Family Care services to have a spouse attendant. The policy that states, "To be eligible for Family Care, the person must not be eligible to receive attendant care services funded through Medicaid", does not apply if the person elects to have a spouse attendant. Even though these people meet the criteria to be referred to CAS, they may elect to receive Family Care services and not be screened or referred to Medicaid for the Elderly and People with Disabilities (MEPD) for a financial determination.

Unmet need policy applies and the caseworker must carefully evaluate tasks provided and tasks not currently provided by the spouse to determine the service plan purchased through Family Care services. Review 2513, Caregiver as the Paid Attendant, and 2514, Who Cannot Be Hired as the Paid Attendant, for more information. The policy must be followed and the spouse assessed as any other caregiver. One exception to the policy is that on Form 2101, Authorization for Community Care Services, the caseworker must note the person is requesting the spouse as the paid attendant.

If the arrangement for the spouse as the attendant ends, then the person must be referred for the appropriate Medicaid funded service.

Note: Document the reason the person is not being referred to Primary Home Care (PHC) or Community Attendant Services (CAS) at each annual redetermination. Review Section 2342.3, Exception Criteria for Referrals to PHC or CAS.

2342.5 Disability Determination for People Under 65 Applying for CAS

Revision 24-5; Effective Nov. 1, 2024

The Texas Health and Human Services Commission (HHSC) caseworker must help certain people under 65 complete the forms required by HHSC for a disability determination. People 65 or over may qualify for Medicaid or Medicaid-funded programs, such as Community Attendant Services (CAS), without a disability determination.

The caseworker must review a person’s disability status by using the State On-Line Query (SOLQ) or Wire Third Party Query (WTPY) systems. A person has a disability established by Social Security if there is a disability onset date on the SOLQ or WTPY systems. If the person under 65 does not have a Social Security established disability, the caseworker must help the person complete Form H1200, Application for Assistance – Your Texas Benefits, Form H3034, Disability Determination Socio-Economic Report, and Form H3035, Medical Information Release/Disability Determination, at the initial face-to-face contact when assessing eligibility.

To determine a disability, HHSC must review evidence, signed by the person’s treating physician, including medical reports which detail the degree and history of the person's diagnosis. The caseworker must inform the person when scheduling the initial face-to-face contact that the caseworker will need the required evidence at their initial contact. If the caseworker schedules the face-to-face contact at least seven calendar days in advance, the caseworker must send Form 2423, Request for Medical Evidence, to the person on the same day of the phone contact to advise the person of the evidence requirement. If the caseworker schedules the face-to-face contact less than seven calendar days in advance, the caseworker must present Form 2423 at the face-to-face contact. The caseworker must not delay the face-to-face contact to allow the person time to get the medical evidence.

The caseworker includes the completed Form H3034, Form H3035 and any evidence obtained at the initial face-to-face contact with Form H1200 following current transmittal procedures to Medicaid for the Elderly and People with Disabilities (MEPD). If evidence was not available at the initial face-to-face contact, the caseworker adds note, No evidence was obtained, in the Section I, Comments about your disability, on Form H3034 before submitting to HHSC for a disability determination.

2343 Confidentiality

Revision 25-4; Effective Sept. 1, 2025

Information for Texas Health and Human Services Commission (HHSC) applicants and other people is confidential and can only be used for purposes directly connected to administration of HHSC services. HHSC routinely shares confidential information with providers because the information shared is directly connected with service administration.

Information can also be shared with other entities if the purpose is directly tied to the administration of services. Consult the unit supervisor before making the decision to share information with people other than the providers.

Code of Federal Regulations, Title 42, Part 431, Subpart F – Safeguarding Information of Applicants and Recipients – (a) Section 1902(a)(7) of the Act requires a state plan to provide safeguards that restrict the use or disclosure of information about applicants and recipients to purposes directly connected with the administration of the plan.

Refer to 1140, Disclosure of Information, on national standards created under the Health Insurance Portability and Accountability Act to protect the confidentiality of individually identifiable health information.

Related Policy

26 Texas Administration Section 271.151(a) 

2344 Rights and Responsibilities

Revision 24-4; Effective Sept. 1, 2024

During the initial visit with the applicant and their responsible party (RP), if appropriate, discuss the information in Form 2307, Rights and Responsibilities. Ensure the applicant understands the significance of their rights and responsibilities.

If the applicant seems unable to understand this information or the complaint process, giving the RP a copy of Form 2307 is essential. Sharing the applicant's rights and responsibilities with the RP is important if it appears the applicant cannot fully understand them. An RP may be a guardian, family member or other person who helps in the development of the service plan or who maintains regular communication with the applicant or department regarding the applicant's well-being.

The applicant must:

• Provide all information needed to establish eligibility and develop a service plan. Falsifying information is illegal and may result in criminal charges filed against the applicant.
• Promptly report changes in income, living arrangements, family size, loss of assistance grants or Medicaid benefits, or other changes that affect eligibility. If the applicant willfully fails to report changes that affect eligibility and receives services they are not eligible for, the applicant may be prosecuted for fraud.

Rights and Responsibilities Documentation Requirements

At Application

At the initial visit, the caseworker must clearly and fully explain the information in the following forms to the applicant. Then, the caseworker must maintain copies in the case record and review them with the applicant or RP as shown in the instructions for each form.

People must receive the following forms and attachments:

• Form 2307, Rights and Responsibilities;
• Attachment 2307-EVV, Electronic Visit Verification Rights and Responsibilities, if applying for Community Attendant Services, Primary Home Care or Family Care Services;
• Form 1581, Consumer Directed Services Option Overview; and
• Form 1584, Consumer Participation Choice, if applying for personal attendant services (PAS).

If the applicant selects the Consumer Directed Services (CDS) option on Form 1584, they must also receive:

• Form 1582, Consumer Directed Services Responsibilities; and
• Form 1583, Employee Qualification Requirements; and      
• Form 1586, Acknowledgement of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) Option.
• Form 1740, Service Backup Plan. Form 1740 is required when the service planning team determines a service is critical to the health and safety of the person. This includes people with priority status.

Review section 6000, Service Delivery Options, for complete information and requirements on CDS.

People applying for Family Care, Community Attendant Services or Primary Home Care, Emergency Response Services (ERS) and Adult Foster Care (AFC) services must be given the following forms for the requested service:

• Attachment 2307-A, Family Care, Community Attendant Services and Primary Home Care Rights and Responsibilities;
• Attachment 2307-B, ERS Rights and Responsibilities; or
• Attachment 2307-F, AFC Rights and Responsibilities.

All applicants must receive Form 2065-A, Notification of Community Care Services, notifying them of the eligibility decision.

Annual Reassessments and Changes

• Clearly document in the case record that the person's rights and responsibilities were reviewed at the annual reassessment.
• Keep the current Form 2307 on file at the annual reassessment if nothing has changed affecting the person's services. Phone numbers and staff names do not constitute a change for completing a new Form 2307. It is important that the person knows how to reach the caseworker and business cards are suggested.
• If the person's services change, they or the RP must receive a new Form 2307.
• As appropriate, review the information on Attachment 2307-A, Attachment 2307-B, Attachment 2307-F and Attachment 2307-EVV with the individual or RP. Complete new forms if PAS, ERS or AFC are being added as new services.
• With the exception of ERS, Home-Delivered Meals (HDM), and Day Activity and Health Services (DAHS), a home visit is required to add a service to the person's service plan.
• Review and offer the choice of service delivery options at the annual reassessment.
• Clearly document in the case record that the choice of service delivery options was reviewed at the annual reassessment.
• Get a new signed and dated Form 1584 at any time the person changes their service delivery option. The caseworker also needs to complete and have the person sign Form 1581, Form 1582 and Form 1583, as appropriate.
• Send Form 2065-A if the case action includes:
  • the addition of a new service;
  • a change in the amount of service;
  • a change in the amount of the person's copayment;
  • a change in priority status; or
  • termination of the case or service.

Note: All forms must be given to the person in their preferred language.

Review Appendix IX, Notification/Effective Date of Decision, for more details or exceptions.

2345 Registering to Vote

Revision 26-1; Effective March 1, 2026

The National Voter Registration Act (NVRA) of 1993 requires the Texas Health and Human Services Commission (HHSC) to:

• offer each person who applies for HHSC services the opportunity to register to vote,
• record the person’s decision on Form 1019, Opportunity to Register to Vote/Declination, and 
• file it in the case record. 

The Community Care Services Eligibility (CCSE) caseworker must also offer the person an opportunity to register to vote at annual reassessments or when notified of a change of address and name change.

The caseworker must help the person complete the voter registration forms with the same degree of assistance they provide the person to complete any CCSE forms. The caseworker also must provide bilingual assistance.

The caseworker may not decide if a person is eligible for voter registration other than to find out if the person is voting age, which is 18, or is a U.S. citizen. The caseworker can verify a person’s age or citizenship if that can be readily determined from information filed with CCSE for other purposes. A person must be offered voter registration help per the NVRA if the person’s age or citizenship cannot be determined.

At the time a person applies for services, at annual reassessments or when changing addresses, they must be given the opportunity to:

• complete VR30, Texas Voter Registration Application, and mail it to the voter registrar; or
• complete VR30 and provide it to CCSE staff to mail to the voter registrar.

If the person wants to complete VR30 during the interview, the caseworker must review the form for completeness in the presence of the person. If the form does not contain all required information, including the required signature, the caseworker returns it to the person to complete. If the person requests the caseworker to mail the form, VR30 must be sent to the appropriate county voter registrar within five business days of the person’s signature.

When CCSE staff offer people the opportunity to register to vote per NVRA requirements, they must also inform them of the option to request a ballot by mail. People may request a ballot by mail if they are:

• out of the county during early voting and on Election Day;
• 65 or older;
• sick or disabled; or
• confined to jail.

They can print a PDF application for a ballot by mail from the Texas Secretary of State website and mail it to the Early Voting Clerk. CCSE staff must also help a person complete any form while they register to vote per current voter registration policy.

Declining to Register

If the person does not wish to complete VR30, they must complete and sign Form 1019. If the person refuses to sign Form 1019, the caseworker must document the refusal on the form. The caseworker must keep each declination form in the case record for at least 22 months after the date of signing.

Annual Reassessments Conducted by Phone

If the person receiving services wishes to register to vote during an annual reassessment conducted by phone, the caseworker must mail VR30 to the person within three business days after the date of the call. If the person does not wish to register to vote, the caseworker must ask the person to complete and sign Form 1019. The caseworker must mail them Form 1019 within three business days after the date of the call. The caseworker must inform the person that Form 1019 must be returned within 30 calendar days after the date of the call. If the person refuses to sign the declination form, or the caseworker does not receive the form within 30 calendar days after the date they spoke on the phone, the caseworker must enter on Form 1019 that the person refused to sign or failed to return the form. CCSE staff must retain each declination form in the person’s case record for at least 22 months after the date of signing.

Change of Address or Name Change

The caseworker must contact the person by phone within five business days after receiving notification of a change of address or a name change and offer the opportunity to register to vote. If the person does not have a phone, the caseworker must mail VR30 and Form 1019 within five business days after being notified of an address change. If the caseworker does not receive either VR30 or Form 1019 within 30 days of mailing the forms, the caseworker must complete Form 1019 to indicate the person failed to return Form 1019.

If the person wants to register to vote, the caseworker must mail Form VR30 to them within three business days after the date of the phone call. If the person does not wish to register to vote, the caseworker must ask them to complete and sign Form 1019. The caseworker must mail Form 1019 within three business days after the date of the call. The caseworker informs the person that Form 1019 must be returned within 30 calendar days after the date of the call. If the person refuses to sign the declination form, or the caseworker does not receive the form within 30 days after the date they spoke on the phone, the caseworker must enter on Form 1019 that the person refused to sign or failed to return the form. CCSE staff must retain each declination form in the person’s case record for at least 22 months after the date of signing.

Additional Guidelines

The caseworker must not:

• influence a person's political party preference;
• display any political party preference or allegiance; or
• make any statement or take any action to:
  • discourage the person from registering to vote; or
  • lead the person to believe that a decision to register or not register has any bearing on the availability of or eligibility for CCSE services or benefits.

If the person has any questions about the voter registration process the caseworker cannot answer, the caseworker must:

• advise the person to call the Office of the Texas Secretary of State toll-free at 800-252-8683; or
• give the person the phone number of the local county voter registrar.

2346 Service Delivery Options

Revision 24-4; Effective Sept. 1, 2024

The Texas Health and Human Services Commission (HHSC) offers applicants and people two options for delivering personal attendant services (PAS). The caseworker is responsible for presenting information on the available service delivery options to the applicant at the initial interview and to ongoing people at the annual review, or when requested.

The service delivery options include the:

• Consumer Directed Services (CDS) service delivery option, managed by the person;
• Agency Option (AO), managed by the agency; and
• additional casework procedures detailed in:
  • 6100, Agency Option (AO);
  • 6300, Consumer Directed Services (CDS).

2347 Texas Medicaid Estate Recovery Program (MERP)

Revision 24-4; Effective Sept. 1, 2024

Under the Medicaid Estate Recovery Program (MERP), the state may file a claim against the estate of a deceased Medicaid recipient, 55 and older, who received certain long-term care services.

The following services and programs are subject to MERP claims:

• nursing facility (NF) care;
• intermediate care facilities for people with an intellectual disability or related condition (ICF/IID), which include state supported living centers;
• Medicaid waiver programs;
  • STAR+PLUS Home and Community Based Services (HCBS);
  • Community Living Assistance and Support Services (CLASS);
  • Deaf Blind with Multiple Disabilities (DBMD);
  • Home and Community-based Services (HCS);
  • Texas Home Living (TxHmL); and
  • Community Attendant Services (CAS).

Go to the MERP website for more information on the MERP.

Community Attendant Services

Form 8001, Medicaid Estate Recovery Program Receipt Acknowledgement, gives written information about the MERP.

Provide Form 8001 to a person applying for CAS at the initial home visit or face to face contact. Do not provide MERP information over the phone.

During the home visit or face to face contact, caseworker must:

• complete page 2 of Form 8001 by entering the name of the applicant, the applicant’s responsible person or their authorized representative (AR), if applicable, and the name of the caseworker on page 2;
• provide the Form 8001 to the applicant, the responsible person or the AR and request they read and acknowledge the information by signing page 2;
• provide a copy of the signed Form 8001 to the applicant; and
• keep a copy of the signed Form 8001 in the case file.

An applicant, a responsible person or an AR may sign page 2 of the Form 8001 to show that they received and understand the MERP information. If the applicant, the responsible person or the AR, refuses to sign the Form 8001, caseworker must check the box on the bottom of page 2 to document the refusal and sign the Form 8001 to show that the MERP information was shared with the applicant.

When providing the written MERP information during the home visit or face to face contact, caseworker must clearly explain the following:

• the Form 8001 is only an informational notice;
• the applicant does not have to sign the form to receive services; and
• refusal to sign the form does not exempt their estate from recovery if it is determined that MERP is applicable at the time of death.

Caseworker may explain program requirements to share MERP information but must not make recommendations about the MERP or speculate if MERP will be applicable upon the applicant's death. Only the MERP caseworker can determine if an applicant meets the grandfathered or exempt status.

Note: All forms must be given to the person in their preferred language.

Direct the applicant, the responsible person, or the AR to the contact information on page 2 of Form 8001 if they have more questions about the MERP.

2348 Retroactive Payments

Revision 24-5; Effective Nov. 1, 2024

The provider agency may be reimbursed for services provided before the date a completed, signed, and dated copy of HHS Form H1200, Application for Assistance – Your Texas Benefits is received:

• for up to three months for a person without Medicaid eligibility at the time of the request for retroactive payment; and
• for an indefinite period for a person who is Medicaid eligible at the time of the request for retroactive payment.

The caseworker must send the completed application to Medicaid for the Elderly and People with Disabilities (MEPD) for a decision about the applicant's financial eligibility.

Note: Someone who may complete or sign an application for an applicant or person may not be on the list of people to whom HHSC can release the applicant's individually identifiable health information. Review section 1150, Personal Representatives, for people who may receive or authorize the release of individually identifiable health information under the Health Insurance Portability and Accountability Act (HIPAA) privacy regulations.

A Medicaid-eligible or categorically eligible person does not have to complete an application when requesting services. Also, a person who requests facility-initiated Day Activity and Health Services (DAHS) does not have to complete an application if they have stopped receiving services by the time they are contacted. The DAHS facility can be reimbursed for facility-initiated DAHS provided to a person who was Medicaid eligible when service was received, even if the person does not complete an application.

The following applies to people receiving Primary Home Care (PHC) or DAHS through provider or facility-initiated services.

If a request for DAHS is received from a Medicaid-eligible person who is not required to complete a written application and is receiving DAHS services, then the person must allow the caseworker to process the initial paperwork if the person plans to continue receiving services.

If the person refuses to participate or allow the caseworker to process the initial paperwork:

• for DAHS, send Form 2065-A, Notification of Community Care Services, for facility-initiated DAHS people with a denial date that is 12 days from the form date; or
• for PHC, follow procedures in section 4644, Applicant Approved for Retroactive Payment and Denied Continued Services by the caseworker, to deny people who are receiving PHC and are applying for retroactive reimbursement.

For situations listed above, deny DAHS or PHC people on Form 2101, Authorization for Community Care Services, with a reason for withdrawal of services.

Review section 4640, Retroactive Payments, for complete procedures relating to retroactive payments.

2349 Procedures for Applicants Aging Out of PCS to PHC

Revision 24-5; Effective Nov. 1, 2024

The Texas Health and Human Services Commission (HHSC) has an agreement with the Texas Department of State Health Services (DSHS) that people receiving Personal Care Services (PCS) are referred for Primary Home Care (PHC) two months before their 21st birthday. Review Appendix XXXIII, Requests for Services from People Under 21 Years of Age, for more information and a listing of DSHS offices.

This time frame is set to ensure there is not a gap in services. The DSHS caseworker makes the referral for intake 60 calendar days before the person's 21st birthday. Referrals from DSHS must be accepted, Form 2110, Community Care Intake, must be completed, and the intake assigned to a caseworker. Regional staff must also check the quarterly Age Out list in case the referral from DSHS is not timely.

Since there are differences between PCS and PHC services, the HHSC caseworker thoroughly explains the allowable PHC services at the initial PHC assessment. PHC may not offer some of the services provided through the PCS program.

The applicant must meet all PHC eligibility criteria, including medical, functional, and unmet need. If the applicant is eligible, PHC services are negotiated to begin on the applicant's 21st birthday. PCS services should end at midnight the day before the applicant's birthday. Coordinate the transition with the PCS caseworker and applicant to ensure there are no gaps in services.

All time frames are applicable, and intake processing must not be delayed. The caseworker must make the home visit within 14 calendar days and send a referral Form 2101, Authorization for Community Care Services, to the selected provider within five business days. Currently, the Service Authorization System Online (SASO) will not allow the processing of referral Form 2101 due to the age edit in the system. Therefore, Form 2101 must be completed manually. This edit will be modified in the future to allow completion of the case before the person's 21st birthday.

Upon receipt of Form 3052, Practitioner's Statement of Medical Need, and the final eligibility determination, the caseworker negotiates the start of care date for the person's 21st birthday, completes a manual authorization Form 2101, and sends it to the provider. Form 2065-A, Notification of Community Care Services, is sent within two business days of sending authorization Form 2101. Since SAS entry cannot be completed until the person's 21st birthday, the caseworker is allowed up to five business days after the 21st birthday to complete the data entry.

If the PCS Person Is Ineligible for PHC

If the person is not eligible for PHC due to a low score on Form 2060, Needs Assessment Questionnaire and Task or Hour Guide, requests voluntary withdrawal, or has no unmet need, the denial code must be entered in SASO. These cases are tracked for reporting purposes.

PCS Caregiver as the Paid Attendant

Refer to section 2422.5, Attendant Policy for People Transferring from Another Personal Attendant Services (PAS) Program, for special procedures regarding caregivers as paid attendants in PCS cases. If a parent or other caregiver has been the paid attendant through PCS, they may meet the criteria to continue to be the paid attendant and would not be listed as Do Not Hire. Caregiver support may also be appropriate in some cases.

2410 Overview of the Assessment Process

Revision 26-1; Effective March 1, 2026

The assessment process determines if the applicant meets all eligibility requirements, including:

• financial eligibility;
• functional eligibility; and
• having an unmet need for services.

The assessment process should produce a case record that clearly documents the results of the caseworker's determination. All processes that can be performed in the Service Authorization System Online (SASO) Wizards must be performed in the system to consider that action complete, including:

• Form 2059, Summary of Client's Need for Service;
• Form 2060, Needs Assessment Questionnaire, Task and Hour Guide; and
• Form 2064, Eligibility Worksheet.

Note: When a caseworker receives a request to add a service to a person already receiving services, they must assess the person to determine that they meet all eligibility requirements for the additional service. This includes determining financial and functional eligibility and having an unmet need for the service. Select Initial Assessment on the interview screen in SASO and run the financial, functional and authorization wizards. Review 7310, Requirement to Use SASO Wizards.

2411 Required Documentation

Revision 24-5; Effective Nov. 1, 2024

The following must be documented in the case record:

• A person’s eligibility based on their categorical status in the Texas Integrated Eligibility Redesign System (TIERS) or current financial and functional status using Form H1200, Application for Assistance – Your Texas Benefits, Form 2060, Needs Assessment Questionnaire and Task and Hour Guide or Form 2064, Eligibility Worksheet.
• A person’s medical, social, environmental, or physical conditions relevant to their functional status using Form 2110, Community Care Intake, Form 2059, Summary of Client's Need for Service, Form 2060, and the case narrative.
• A person’s degree of self-sufficiency and the tasks they can perform using Forms 2110, 2059 and 2060.
• Environmental adaptations that are being used or could be used to help the person achieve or maintain their maximum level of self-sufficiency using Form 2059.
• People who are resources, including family, friends, and community networks, that the person now uses or who are available to perform or help with activities of daily living using Form 2059 and Form 2060, Part A.
• Agency resources in the community available to provide any of the services needed by the person using Form 2059 and Form 2060, Part A.
• Form 8001, Medicaid Estate Recovery Program Receipt Acknowledgement, for Community Attendant Services applicants or responsible parties.

In some areas of Texas, the Area Agency on Aging (AAA) may submit a completed Form 2060 based on the assessment of services it provides. If a completed Form 2060 is received, review the information as part of the assessment process.

Note: Review Section 3000, Eligibility for Services for detailed explanations of financial eligibility assessment and determination procedures.

2420 Reserved for Future Use

Revision 24-3; Effective July 1, 2024

2421 Review of the Community Care Intake Form

Revision 24-5; Effective Nov.1, 2024

Review Form 2110, Community Care Intake, for all relevant information. Make sure the practitioner is the applicant's current practitioner and that the name, address and phone number listed are correct. If the applicant provided a rural route address, ask for the updated street address. If the person states they do not have a new address, continue to use the address provided. Take no action if the street-style address is not provided. Ask the person to update their information with the Texas Health and Human Services Commission if they are notified by the U.S. Postal Service of a new address.

Verify that the responsible party is the primary contact for the applicant and that the name, address, and phone number are correct. On Form 2110, list any other family members or informal supports who can be contacted if the applicant cannot be reached. Review the requested services and address those during the interview and in the documentation.

2422 Form 2059, Summary of Client's Need for Service

Revision 24-5; Effective Nov. 1, 2024

The purpose of Form 2059, Summary of Client's Need for Service, is to document the applicant's:

• medical diagnosis and physical condition;
• functional limitations;
• home environment;
• living arrangements; and
• family and community supports.

Record all information reported by the applicant or informal supports during the home visit on Form 2059-W, Summary of Individual's Need for Service Worksheet. This information is entered into Service Authorization System Online  (SASO) and will generate Form 2059.

Carefully observe and use interviewing skills during the initial home visit and throughout the assessment process. This is necessary to collect critical information about the person's functional and mental abilities, as well as community and family resources. People may demonstrate functional abilities while responding to questions about their home and living environment or medical problems. They may reveal information about family resources while responding to questions about financial eligibility. They may reveal intellectual and developmental disabilities or lack of mental clarity in the way they respond to questioning throughout the interview. During the interview, be alert for any indications of abuse, neglect or exploitation. If any of these conditions are present, refer the person to the Texas Department of Family and Protective Services (DFPS), Adult Protective Services.

2422.1 Medical Diagnosis and Functional Limitations

Revision 25-2; Effective March 31, 2025

Ask the applicant for information about their medical diagnosis and physical and functional limitations. Record this information on Form 2059-W, Summary of Individual's Need for Service Worksheet.

2422.2 Home Environment

Revision 24-5; Effective Nov. 1, 2024

The person's functional status is always relative to the home circumstances where the person performs the activities of daily living. For example, the person may have physical limitations that would not affect their abilities to perform specific personal care tasks if they lived in a home complete with all modern conveniences. If, however, their home contains only minimal household equipment, their inability to perform their personal care tasks could be compounded. Always assess a person's functional capacity in relation to the home environment where the tasks are performed daily. Service plans are developed to be carried out in specific home environments and each plan should relate specifically to a functional assessment done in that environment.

Observe and ask questions about the person's home and immediate environment to assess their ability to perform activities of daily living. Determine if the environment affects the person's ability to perform these activities or otherwise affects their health and safety.

Guidelines for Assessing the Home Environment

Using the following guidelines, assess the home environment and document the results on Form 2059-W, Summary of Individual's Need for Service Worksheet, to be entered in the Service Authorization System Online  (SASO). When observing the person's home and immediate environment, assess the following:

• Does the structure of the house or dwelling create an environment that is safe and adequate for the person's unique needs?
• Are there assistive devices and equipment necessary for the person to live safely or that would improve their safety? Note: These include ramps, grab bars, wide doors, lowered light switches, and adequate light for safe visibility.
• Is the home clean enough and orderly enough to be safe for the person's lifestyle?
• Does the home pose any critical health hazards?
• Do they have neighbors who are or might be resources for helping with any special monitoring the person might need because of a unique health or physical problem?
• Is the neighborhood safe to allow the person to move safely in and out of their home as needed?
• Is the person safe from physical harm in their own home?

Home Arrangement

Is the person the owner of their home, or do they live in an apartment or with friends or relatives? The person may pay rent, own the home or live cost-free.

Is the person homeless and no friend or relative is available to provide a home? If the person has insufficient income to rent a suitable home, they may be living in a public shelter or an exposed setting. Refer the person to Adult Foster Care (AFC), Residential Care (RC), public housing, or other community living resources. A referral to Adult Protective Services (APS) may be needed.

Home Condition

Is the person's home:

• Adequate — Physically safe and arranged or equipped so the person lives safely and performs normal activities of daily living? Although adjustments may be desirable, they are not necessary for safety.
• Inadequate Questionable — The residence presents serious limitations conducting activities of daily living, or safety hazards exist because of a need for major repairs, addition of utilities, or assistive devices. Check the appropriate boxes on Form 2059-W.
• Inadequate Unsafe — The residence is an unsafe environment for the person. The structure is in a severe state of disrepair, contains critical health hazards, or prevents one from performing the normal activities of daily living. The person may need to be moved for their health and safety. A referral to APS may be appropriate. Check the appropriate boxes on Form 2059-W.

2422.3 Living Arrangement

Revision 24-5; Effective Nov.1, 2024

The caseworker documents on Form 2059-W, Summary of Individual's Need for Service Worksheet, Item 4, if the applicant lives alone, with a spouse, with family or friends, or if they are in adult foster care or a residential care facility. In Item 5, list the name and relationship of all household members and indicate with a Y that they are in the household. Note if any of the household members receive services or are applying for services.

2422.4 Documentation of Caregivers

Revision 24-5; Effective Nov. 1, 2024

Ask the person if they receive help with their activities of daily living and list the names and relationships of all caregivers. These people may be family members, friends or neighbors. List the tasks performed by each caregiver on Form 2059-W, Summary of Individual's Need for Service Worksheet. Under Caregiver Status, indicate if there is a reason the caregiver cannot meet all the person's needs, such as working full time, having ill health, needing caregiver support, or providing continual care. For household members who are not performing any caregiver tasks, leave the caregiver status blank. If a household member states they are unwilling to help the person with any tasks, note this in the Caregiver Status on Form 2059-W.

The caregiver will be assessed during the functional assessment. Review Section 2433.1, Assessment of the Caregiver.

Determine if the caregiver needs caregiver support as defined in Section 2512, Caregiver Support, and develop the service plan accordingly.

2422.5 Attendant Policy for People Transferring from Another Personal Attendant Services (PAS) Program

Revision 24-5; Effective Nov. 1, 2024

For people applying for Community Care Services Eligibility (CCSE) personal attendant services (PAS) and the caregiver has been the paid attendant in another HHSC program, the following guidelines must be applied to people who are transitioning from the following programs:

• People who are no longer eligible for STAR+PLUS or the STAR+PLUS Home and Community Based Services (HCBS) program, who are being assessed for Primary Home Care (PHC), Community Attendant Services (CAS), or Family Care (FC); and
• People transitioning from the Texas Health Steps Comprehensive Care Program (THS-CCP) Personal Care Services (PCS).

The applicant must meet the unmet need criteria, but the current circumstances will be considered.

During the initial interview, if the caregiver has been the ongoing paid attendant and would like to continue as the paid attendant, the caseworker will ask the caregiver the following question: "Would you continue to provide care if you are not being paid to provide the care?"

If the response is "No," determine the tasks the caregiver has been paid for in the previous program and if the person still needs help with those tasks. Determine which tasks will continue as caregiver tasks and develop the service plan accordingly. Document the caregiver's response and send Form 2067, Case Information, along with the referral packet, to the provider advising that the caregiver had previously been the paid attendant and is eligible to be the paid attendant.

If the response is "Yes," evaluate if there is any unmet need or if caregiver support is required. If services continue, the caregiver cannot be hired. If there is no need for caregiver support or no unmet need, the applicant is denied services.

Caseworkers must follow this policy for people applying for HHSC Primary Home Care (PHC), Community Attendant Services (CAS), or Family Care (FC) who are transitioning from one of the programs listed above.

2422.6 Common Household Tasks, Duplicate Services and Services Provided to Other Household Members

Revision 25-3; Effective June 1, 2025

If a person lives with others, do not purchase services normally provided as part of the household routine. Examples are meal preparation, shopping, laundry, and housekeeping for the person, unless the person has unique needs.

If a person lives with others, determine if they need unique tasks performed apart from the household's tasks and if performing these tasks imposes more burdens of time and responsibility on the household members. Unique tasks are attributable to the person's problems. Examples include incontinence, a need for a special diet, food preparation, extra shopping or special housecleaning caused by the person's behavior. Allowable tasks also include cleaning up after personal care tasks, cleaning the person's room and the bathroom used by the person. If it is determined the person's needs impose special and extra activities on the household members, document these needs on Form 2060, Needs Assessment Questionnaire and Task and Hour Guide.

Services Provided to Other Household Members

Identify if services are being provided to any other household member by the Texas Health and Human Services Commission (HHSC) or another agency. If services are being provided, assess if they meet some of the person's needs and would affect their service plan. If two or more people in a household receive Community Care Services Eligibility (CCSE) services, they are considered companion cases. Review 2441.3 Time Allocation for Companion Cases.

Example: A person’s spouse receives Community Care Services Eligibility services, and an attendant performs cleaning, laundry, and meal preparation as part of that service plan. Some of those services also benefit the spouse or duplicate services that they need. In this case, divide the time for common tasks between the people and authorize the task for both people. Refer to the maximum times listed on Form 2060 for companion cases.

If the person lives with a household member receiving non-CCSE services discuss with the person to determine if any tasks provided by the other agency might meet some of the applicant’s needs or would affect the time authorized for household tasks. Document any extenuating circumstances if the person needs time below the individual range

Refer to 4400, Family Care Services, and 4600, Primary Home Care and Community Attendant Services, for specific information about situations when two people in the same household receive attendant services.

2422.7 Assessment of Social and Community Resources

Revision 24-5; Effective Nov. 1, 2024

Assess the person's community and social network resources, such as churches, civic clubs, and voluntary affiliations, to determine if any of these entities provide services or can do so. Also, identify available service agencies that serve older people and people with disabilities and might be able to provide a service needed by the person. Always determine if any of these sources can help the person before services from the Texas Health and Human Services Commission (HHSC) are authorized. Review Appendix XV, Services Available from Other State Agencies, for help identifying alternate sources of assistance. When possible, refer to local resource directories for information about services in a person's community. Document the use of or referral to other service agencies on Form 2059-W, Summary of Individual's Need for Service Worksheet.

All other services available to the person must be considered and used before HHSC services are authorized.

2423 Guardianship

Revision 24-3; Effective July 1, 2024

A Community Care Services Eligibility person may need a guardian if they:

• appear to be incompetent; or
• are incapacitated and cannot care for themselves or manage their property and financial affairs.

If the person's incompetence or incapacity results in them being in a state of abuse, neglect or exploitation, the caseworker must make a referral to Adult Protective Services (APS). Unless ordered by a court to do so, the caseworker must not file a petition for guardianship or assume guardianship of the person or the estate of a Texas Health and Human Services Commission (HHSC) person.

If the court intends to appoint the caseworker as guardian, the caseworker must advise the court that serving in that capacity will violate HHSC policy. If the caseworker is appointed guardian by the court, the supervisor and regional attorney must be notified immediately. If a referral to APS, Texas Department of Family and Protective Services, has not been made, make one now.

2430 Functional Assessment

Revision 25-4; Effective Sept. 1, 2025

Use Form 2060, Needs Assessment Questionnaire, Task and Hour Guide to determine:

• the person's functional eligibility;
• the person’s ability to carry out activities of daily living;
• what they should continue to do for themselves to maintain their current level of self-sufficiency;
• what they cannot do for themselves because of physical limitations, mental limitations or both;
• which resources are available to help with specific tasks;
• if the person has an unmet need; and
• how much service the person will receive, if eligible.

A person's functional level is based on:

• their physical condition;
• their medical problems and the functional limitations they impose;
• their mental clarity and limitations and the effect they have on performing activities of daily living; and
• the condition of their home environment.

The age of the person being assessed for services should not be considered when determining the level of functional need. Example, the applicant is a 3-month-old infant whose mother is applying for Community Attendant Services (CAS) for the child. The infant will need help with most of the activities of daily living and would, therefore, score a 3 on those tasks. The fact that the functional need is the direct result of the person's age should not be considered when assigning a score for the task.

If the person appears eligible for Community Care Services Eligibility services based on age, income and resources, and they request services beyond information and referral, complete Form 2060, Part A, to determine the functional eligibility for services. This assessment helps determine if the person:

• has functional needs,
• what kinds of functional limitations they experience,
• which tasks they need help with, and
• if their mental clarity contributes to their need for help.

Related Policy

26 Texas Administrative Code Section 271.63(a)

2431 Form 2060, Part A, Functional Assessment

Revision 24-3; Effective July 1, 2024

Program Standard: The caseworker must score each item on Form 2060, Needs Assessment Questionnaire and Task and Hour Guide, Part A, Functional Assessment. They then must accurately compute the total score to determine if the person is eligible for Community Care Services Eligibility services. Use the spaces under each item, as needed, to explain the person's limitations or their accommodations for their disability. Refer to the form instructions for detailed information about scoring Form 2060, Part A. Appendix XVII, Service/Score Code Guide, which indicates the score requirement for each service.

During a face-to-face interview, ask the person each question on Form 2060, Part A, as the question is stated on the form. Then, ask more questions to gain a complete understanding about the degree of the person's ability or inability to carry out activities of daily living. Careful assessment of the person reveals what they can do for themself, what they should continue to do for themself to maintain their current level of self-sufficiency, and what they cannot do for themself because of physical limitations or mental limitations. When conducting an assessment, use the following scale of disability and follow the detailed definitions of impairment levels found in the instructions for Form 2060, Part A.

To determine the severity of the person's impairment, consider the following factors:

1. Person's Perception of the Impairment — Does the person view the impairment as a major or minor problem?
2. Congruence — Is the person's response to a particular question consistent with the person's response to other questions and consistent with what has been observed?
3. Person’s History — Probe to understand the person's history about the current situation and the person's attitude about the severity of the impairment. For example, has the person  always kept a messy house and is not concerned because they cannot perform housekeeping tasks? Has the person always eaten only one meal a day and is not interested in eating more often? How has the impairment changed the person's lifestyle?
4. Person's Right to Self-Determination versus Danger to Self — Consider the consequence to the person if they choose not to take medications, bathe or adhere to a special diet.
5. Lack of Facilities — Absence of facilities for bathing, laundry, phone calls or meal preparation may indicate an impairment. The impairment and its degree will depend on the person's accessibility to the facility, ability to use it and ability to make satisfactory accommodations in the absence of the facility.
6. Adaptation — If the person has adapted their physical environment or clothing to the extent that they are able to function without help, the degree of impairment will be lessened. However, the person will still have an impairment.
   Note: Medication is not considered an adaptation to the person's functioning like a walker is. The person is not considered to have an impairment if the medication is working. The person is rated on how they are functioning at the time of the interview, regardless of the status of taking medication.

The following chart provides a general guide for assessment. Whether the person is taking medication, forgetting or refusing medication, or taking medication incorrectly, they are still assessed on their current level of functional ability.

Situation: The person has problems with dizziness and balance, which could affect scoring on the transfer or ambulation and balance questions.

The caseworker must document the reason in situations where the task score on Form 2060 is inconsistent with the amount of time allotted for that task. Example: A case reader may decide to rate Standard 10 unmet if a person scores 1 on all Form 2060 tasks, yet the maximum amount of hours for each are purchased and case documentation does not explain the discrepancy.

2432 Scoring Persons Who Cannot Respond

Revision 24-5; Effective Nov. 1, 2024

On some occasions, the caseworker may need to assess small children, infants, or people who are unconscious or otherwise non-responsive. Use Form 2060, Needs Assessment Questionnaire and Task and Hour Guide to conduct these assessments. Allow the caregiver to respond if the person cannot. In scoring each item, use the caregiver's response, the caseworker's observations, and any knowledge the caseworker may have about the person from other sources.

2433 Determining Unmet Need in the Service Arrangement Column

Revision 25-4; Effective Sept. 1, 2025

Regardless of a person’s functional eligibility as determined by their score on Form 2060, Needs Assessment Questionnaire, Task and Hour Guide, they can only receive Community Care Services Eligibility (CCSE) services if they have an unmet need for those services.

Unmet need is defined as a requirement for assistance with activities of daily living that cannot be adequately met on an ongoing basis by friends, relatives, volunteers or other service agencies.

For any task listed on Form 2060, Needs Assessment Questionnaire, Task and Hour Guide, the Service Arrangement Column will determine if the person has an unmet need to assess their overall eligibility based on unmet need. Review questions 1 through 15 and ask the person the following questions.

If the impairment score is 1 – Ask the person if they can perform the task by themselves, even though it may be difficult for them.

• If the answer is Yes, enter S in the service arrangement.
• If the answer is No, ask the person who helps them with this task. If the person says a caregiver helps them, enter C for Caregiver in the service arrangement. List the caregiver's name, relationship and task on Form 2059-W, Summary of Individual's Need for Service Worksheet, if it is not already entered.
• If the person says they receive help from another agency, enter A for Other Agency in the service arrangement. List the name of the agency on Form 2059-W.
• If the answer is No and the person says they have no help from any source and needs help to perform the task, enter P for Purchased in the service arrangement.

If the impairment score is 2 or 3 – Ask the person if they receive help with this task.

• If the answer is Yes, ask the person who helps them with the task. If the person says a caregiver helps with the task, enter C for Caregiver in the service arrangement. List the caregiver's name, relationship, and task on the worksheet, Form 2059-W, if it is not already entered.
• If the person says they receive help from another agency, enter A for Other Agency in the service arrangement. List the name of the agency on Form 2059-W.
• If the answer is No and the person says they have no help from any source and needs help to perform the task, enter P for Purchased in the service arrangement.

If the person says they receive some help from others, but it does not meet all their needs for a specific task, enter P/C. Document the part of the task performed by the caregiver in the Tasks Performed section on Form 2059-W.

Related Policy

26 Texas Administrative Code Section 271.63(b)

2433.1 Assessment of the Caregiver

Revision 24-5; Effective Nov. 1, 2024

For each task marked C on Form 2060, Needs Assessment Questionnaire and Task and Hour Guide, assess the capability, dependability, availability, and willingness of the caregiver. Consider and discuss family and job responsibilities, and the physical demands of caregiving. For each task, determine by observation and by asking the applicant or caregiver the following questions:

1. Is the caregiver physically and mentally able to perform the task?
2. Is the caregiver dependable in performing the task on the required schedule?
3. Is the caregiver available at the time the person needs the task performed, either scheduled or on-demand?
4. Is the caregiver willing to perform the task on a regular and ongoing basis?

It may be necessary to talk with the person's current caregiver to assess their contribution to the person’s care needs accurately. If the caregiver cannot join the applicant for the initial face-to-face visit, get as much information as possible from the applicant and contact the caregiver by phone to verify that the caregiver is willing to provide the tasks. Do not delay service initiation if the caregiver cannot be reached.

If, for any task, it appears the caregiver cannot adequately meet the applicant's needs or it is apparent from caseworker observation that the task is not being adequately performed, discuss with the applicant if some or all of the task should be purchased.

Be sensitive to any indications of abusive or neglectful behavior on the part of the caregiver, and, if necessary, make a referral to Adult Protective Services.

2433.2 Exploring Other Resources for Meeting the Applicant's Needs

Revision 26-2; Effective June 1, 2026

Explore other possibilities for resources with the person. Ask if family members pay someone to help the person and if the current help is enough. Use observations about the caregiving arrangement to determine if needed tasks are being adequately performed. If a person's need for help with a particular task is being adequately met and the help is expected to continue, do not authorize purchased services for that task. If the need for help with a particular task is not being met or is only partially met, ask the person and family if anyone would voluntarily provide the needed help. 

Explore the use of any identified volunteers. If voluntary help cannot be obtained, explore the use of community resources. Also consider service options from other groups or agencies. Review 2535, Involvement of Volunteer Resources, and 2530, Other Resource Services, for possible resources to meet the person's needs. If the person's need for help cannot be met in any other way, enter P for the task on Form 2060, Needs Assessment Questionnaire, Task and Hour Guide. If Home-Delivered Meals is the only service being purchased, complete the service arrangement column and do not allocate time on Form 2060.

If a person's needs for help are now being met and the person or family decide the present care arrangements cannot be continued, tell the person or family that the person may reapply for services when the current arrangement is discontinued. If, during the initial interview, the person or their family knows the present care arrangements will discontinue within 30 calendar days, proceed with the application process.

Examples

• A person's sister, who is providing the care, takes a job and will begin work on a specified date.
• A live-in relative who is providing the care plans to leave town on a specific date.
• A family member who is paying a caregiver will soon be unable to continue because of new financial obligations, which will begin on a specific date.

If someone who has been paying for care intends to discontinue the arrangement on a specific date within 30 calendar days, proceed with the application. Otherwise, offer to take an application at the time the care arrangement is discontinued. If someone will continue to purchase some of the care, determine if the applicant has an unmet need for any more care. If someone is willing to pay for services only while the person is on an interest list, this does not affect the person's unmet need for services purchased by HHSC. However, if someone is willing to pay for services after the person comes off the interest list, there is no unmet need.

In some situations, a caregiver may quit employment to stay home and provide care for the applicant and is requesting to be the paid attendant. In this situation, the caseworker must get verification that the person quit employment within 30 calendar days before or after the application date. The caregiver may be considered as a potential attendant. In the Service Arrangement column of Form 2060, note the tasks that the caregiver will voluntarily provide and those tasks that will be purchased. Review 2513, Caregiver as the Paid Attendant, for more information.

This policy also applies to ongoing cases where a caregiver who has been working full-time quits to stay home and provide care for the person. The caseworker must verify that the person quit employment within 30 calendar days of the request for the change.

When the Service Arrangement Column of Form 2060 is completed, review the results to determine if the person has an unmet need. If all responses are S, C or A, the person has no unmet need and is not eligible for services. Advise the person that they are not eligible at this time and that they may reapply if their circumstances change. Be sure to adequately document this information in the Service Authorization System Wizards with the appropriate denial code and send the applicant Form 2065-A, Notification of Community Care Services.

If tasks are marked P on Form 2060, continue to the Task and Hour Guide section.

2434 Support Score and Establishing Priority

Revision 24-5; Effective Nov. 1, 2024

If an applicant for Primary Home Care (PHC), Family Care (FC), or Community Attendant Services (CAS) has a functional score of 3 and the service arrangement for a priority task feeding, toileting, transfer, meal preparation is a P, then a support score must be entered for these tasks on Form 2060, Needs Assessment Questionnaire and Task and Hour Guide. Determine the likelihood of that task being done if the attendant does not show up during a typically scheduled service shift. Using the following scale, enter the score in the Form 2060 Support Score box by the appropriate item.

In determining this support score, do not consider caregivers as available if they would be at work or school, even if they could come to the person's home if the attendant were not there. Do not enter a support score for an item if either the task is not purchased or the person's score for that task is not "3."

If the support score is 4 on any of the priority tasks, the person will be designated as a priority person. Review Section 2540, Priority Status People for more information on this designation process.

2440 Use of Form 2060, Part B, Task and Hour Guide, and Part C, Task/Minute and Subtask Guide

Revision 24-5; Effective Nov. 1, 2024

For all personal attendant services (PAS) cases, the caseworker uses Part B and Part C of Form 2060, Needs Assessment Questionnaire and Task and Hour Guide to determine the number of purchased services needed by a person.

The Part C, Task/Minute and Subtask Guide, provides a uniform approach to the authorization of services based on a minute range per task and impairment score. Each impairment score for each task has a minimum and maximum allotted time. It is mandatory to follow the minute guideline and check the subtasks for each task to document the type of help needed and to support the time allocated for that task. Review the Form 2060 Instructions for complete directions for completing the form.

Form 2060, Pages 1-5, must be manually completed during the home visit initial assessment for an applicant who will receive PAS. Review the Task/Minute and Subtask Guide at each reassessment and initial the form. When there is a change in hours, either complete a new Form 2060 manually or update the current Part B and Part C.

Refer to Form 2060, Part C, for guidelines on the number of minutes to be allowed per task. The amount of time allowed for any task should be determined by accounting for:

• the amount of help the person will usually need;
• the availability of anyone else to help with the task;
• which specific subtasks and activities need to be purchased;
• environmental and housing factors that may hinder, or facilitate, service delivery; and
• the person's unique circumstances.

Discuss each task thoroughly with the person to decide if they need help with it, how much time is required to perform it, and how often each week the task must be performed. The total time allowed for each task must be within the minimum and maximum time limits for the impairment score, indicated on Form 2060.

Negotiate service authorizations with people to reach an agreement about:

• the number of tasks and activities the person needs help with;
• how often the help is needed; and
• the amount of time needed by the provider to carry out those tasks and activities per week.

All appropriate subtasks must be checked to show the specific tasks the person needs. A person scoring a 2 or 3 may need all subtasks under the impairment score of 1 and additional subtasks under the impairment score of 2. The time allotted must be within the range of the impairment score.

Time above the minute range may only be allotted with documented supervisory approval. Time below the minute range may be allotted with documentation of the person’s extenuating circumstances.

2440.1 Requesting Supervisory Approval for Time Above the Minute Range

Revision 24-3; Effective July 1, 2024

When a person has extenuating circumstances and requires a deviation in the time range, the caseworker must request supervisory approval to authorize time above the minute range for the task or impairment score. The caseworker must document why the person requires minutes outside the range for the task or impairment score level. The deviation must be discussed verbally or by email with the supervisor, and the supervisor must approve or disapprove the deviation.  The caseworker must document the supervisor's approval date on Form 2060 in SASO.

Refer to 2441, Circumstances When Supervisory Approval is Not Required.

2441 Circumstances When Supervisory Approval is Not Required

Revision 24-5; Effective Nov. 1, 2024

In some situations, the person may have extenuating circumstances and a compelling reason that require subtasks in a lesser impairment score to be authorized for a task. The two situations where the caseworker may allot time for subtasks in a lesser impairment score without supervisory approval are if the person has:

• extenuating circumstances and is requesting only subtasks in a lesser impairment score; or
• a caregiver or other agency providing some of the subtasks.

The caseworker documents:

• the person's extenuating circumstances and the reason tasks with a lesser impairment score are authorized; or
• the part of the task the caregiver or other agency provides.

2441.1 Exception for a Compelling Reason

Revision 24-5; Effective Nov. 1, 2024

In some situations, a person may request that tasks not be performed for them even though they have an impairment and may not be able to perform the task for themselves.

If a person has a compelling reason for not wanting any of the subtasks under the appropriate impairment score but only wants subtasks listed in a lower impairment score, the caseworker must document the person's request and allocate minutes in the minute range for the subtasks selected. The caseworker must document the reason, and no supervisory approval is required.

Example: The person scores a 2 on bathing. They need help with drying. However, when discussing subtasks, they state they would like standby assistance for safety and drawing of water, all under the impairment score of 1. They state their skin is very sensitive and they would not allow help with drying as they are afraid it would hurt them. The subtasks checked are all under the impairment score of 1, so ten minutes is allowed. Documentation is required to explain the variance. No supervisory approval is required.

Review Form 2060, Needs Assessment Questionnaire and Task and Hour Guide, and Instructions for additional information.

2441.2 Exception for Assistance from a Caregiver or Other Agency

Revision 24-5; Effective Nov. 1, 2024

If a person has a caregiver or other agency performing part of a task and only subtasks with a lower impairment score are needed, the caseworker must document the person's request and allocate minutes in the minute range for the subtasks selected. The caseworker must document the reason and the part of the task the caregiver or other agency performs. No supervisory approval is required.

Example: The person scores a 2 for bathing, but only wants help laying out supplies and drawing water because their daughter provides all hands-on assistance with the bathing task. The task is marked P/C. The subtasks under the impairment score of 1 are checked, and ten minutes is allowed for the subtasks to be purchased. Documentation is required to explain the variance.

2441.3 Time Allocation for Companion Cases

Revision 24-5; Effective Nov. 1, 2024

For companion cases, base time allocated for general household tasks, including cleaning, shopping and meal preparation, on the companion minute range on Form 2060, Needs Assessment Questionnaire and Task and Hour Guide, not the individual range. Time is assigned per person based on the person's impairment score. Check the box(es) in the Total Minutes Per Week column for cleaning, meal preparation, and shopping to show that time is authorized for these tasks in the companion case. When there are more than two companions in the household, assign time based on the person's impairment score using the companion minute ranges.

When there are more than two people in the household, the caseworker continues to use the companion minute range based on the person's impairment score.

Example: On cleaning, Mr. Jones scores a 3, and Mrs. Jones scores a 1. Mrs. Jones can do some light housekeeping, but due to her husband's incapacity, he needs all cleaning tasks performed in his area. Mrs. Jones is allowed the maximum of 45 minutes under impairment score 1 in the companion range. Mr. Jones is allowed the maximum of 180 minutes under impairment score 3 in the companion range.

Review Form 2060 Instructions for more examples and guidance on companion cases.

2442 Calculation of Time to be Authorized

Revision 24-5; Effective Nov. 1, 2024

Use the following procedures to calculate the total amount of time needed each week.

1. Multiply the number of minutes needed to conduct each task by the number of times the task will be performed each day to reach a daily total of minutes for each task. Times must be shown in five-minute increments. If necessary, round the time up to the next five-minute increment.
   
   Example: If a person needs to prepare meals twice a day and the preparation requires the maximum amount of time, multiply 30 minutes by two to reach a daily total of 60 minutes.
2. Multiply the daily total of minutes for each task by the number of days per week the attendant will conduct that task. Times must be shown in five-minute increments and rounded up to the next five-minute increment if necessary.
3. Add the required weekly minutes for all tasks and divide the total by 60 minutes to determine the weekly total in hours.
4. Round the weekly number of hours to the next highest half unit to determine the number of units to be authorized. Example: If a person needs 7 hours and 10 minutes of service each week, authorize 7.5 units of service. The number of hours must be correctly rounded up for accurate authorization of services.

Use Form 2060, Needs Assessment Questionnaire and Task and Hour Guide to calculate the hours of service to be purchased. The correct number of hours must be authorized on Form 2101, Authorization for Community Care Services. Write comments in the Service Authorization System Online (SASO) Impairment Scoring" window in the Functional Wizard.

Tasks identified as needing to be purchased must be authorized on Form 2101. Tasks marked P in the Service Arrangement column of Form 2060 must also be marked on Form 2101. The meal preparation task may be marked P on Form 2060 and not marked on Form 2101 as long as the person is receiving home-delivered meals. A separate Form 2101 as authorizing meals is sent to the home-delivered meals agency.

2443 Balancing Incentive Program, Level II Assessment

Revision 24-3; Effective July 1, 2024

The Balancing Incentive Program (BIP) provides additional Federal Matching Assistance Percentage (FMAP) funds to states that initiate reforms to increase nursing home diversions and access to non-institutional long-term services and supports. As part of the effort to increase access to additional federal funds and meet BIP requirements, the Texas Health and Human Services Commission (HHSC) administers the Level II Assessment to all people requesting or receiving Primary Home Care (PHC), Community Attendant Services (CAS) and Day Activity and Health Services (DAHS) Title XIX. The Level II Assessment includes:

• Part A of the Functional Assessment of Form 2060, Needs Assessment Questionnaire and Task and Hour Guide; and
• Form 2060-B, Needs Assessment Addendum.

The BIP was created by the Affordable Care Act of 2010 and improves the state’s ability to serve more people by increasing access to non-institutional long-term services and supports. The BIP allows states to adhere to the integration mandate of the Americans with Disabilities Act (ADA), as required by the Olmstead decision.

The caseworker will complete the Level II Assessment, Form 2060-B, for initial assessments, annual reassessments, and for a significant change request for a new service.

For changes in services, the caseworker will complete:

• Form 2060, Part A, Functional Assessment, if applicable;
• Form 2060, Part B, Task and Hour Guide;
• Form 2060, Part C, Task/Minute and Subtask Guide; and
• Form 2060-B.

The following are examples of the forms that are completed when a request is made for a change in service:

Examples:

Example A – A person receiving CAS calls the caseworker requesting transportation help. The caseworker completes Form 2060, Part A and Form 2060-B. Only complete Form 2060, Part B and Part C, if applicable. In reviewing the required forms, the person only requests transportation and does not wish to have the service plan for their attendant care services changed. The caseworker will send a referral for transportation only. No other action is required.

Example B – A person receiving CAS calls the caseworker to request home-delivered meals. The caseworker completes Form 2060, Part A, and Form 2060-B and, if applicable, Form 2060 Part B and Part C. In reviewing the required forms, the caseworker places the person’s name on the Home-Delivered Meals Interest List and increases the time allotted for meal preparation for their attendant services. The caseworker completes the change per Section 2721.4, Revising the Service Plan, and Section 2721.6, Authorizing and Documenting Changes.

The caseworker determines if a referral is needed for HHSC services or non-HHSC services based on the information collected from Form 2060-B. The caseworker discusses and gets approval to make a referral with the person to non-HHSC services. Referrals may include:

• behavioral health services;
• supported employment or employment assistance;
• transportation assistance;
• help with instrumental activities of daily living, and
• help for other medical conditions not previously addressed.

The caseworker documents the referrals made for the person in Section III of Form 2060-B, including any need for referrals identified but refused by the person. No data entry is required in the Service Authorization System Online (SASO) resulting from completing Form 2060-B only.

The person keeps the right to participate in their service plan development. They can also refuse all or part of any services and be informed of the likely consequences of such refusal, including referral to non-HHSC services.

Identified needs for referrals agreed to by the person are considered requests for information and referral. The caseworker makes use of applicable existing referral policy to help the person with the appropriate referral located in:

• Section 2422.7, Assessment of Social and Community Resources;
• Section 2530, Other Resource Services;
• Section 2535, Involvement of Volunteer Resources;
• Section 2743, People Receiving Services through Local Authorities;
• Appendix XV, Services Available from Other State Agencies.

Referrals for behavioral health needs identified on Form 2060-B may be made to local mental health authorities. Use the local phone numbers available on the Mental Health and Substance Use page.

2510 Service Plan Development

Revision 24-5; Effective Nov. 1, 2024

Program Standard: Caseworkers must develop service plans that accurately authorize appropriate services for people based on their needs, eligibility and priority level.

After completing Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, to assess the needs and unmet needs of the person, discuss service planning with the person or their family members. Consider all possible available resources through Community Care Services Eligibility (CCSE) services or other community resources. Evaluate if the person is interested in receiving Home-Delivered Meals (HDM), Emergency Response Services (ERS), or attending Day Activity and Health Services (DAHS), or other community centers. Review Form 2110, Community Care Intake, and address all services requested at the time of intake. Document any decisions made about the use of those services.

To the extent of their abilities, eligible people must be involved in the development of their service plans. Discuss service planning with a person or their caregivers during the initial visit. Whenever possible, complete service planning during the visit. If this is not possible, service planning may be completed after the visit and after financial eligibility has been determined.

The discussion with the person, and caregivers, should include the type of services that may be appropriate for purchase after the unmet need has been addressed and determined. To maintain self-sufficiency and a level of independence:

1. Allow the person the opportunity to continue performing tasks they prefer to do themself, even though they may be challenging for them.
2. Explain to the person that Texas Health and Human Services Commission (HHSC) programs are not designed to replace the care that caregivers now provide or are able and willing to provide over time.
3. At the conclusion of the initial visit, ensure that the person fully understands precisely what services HHSC may provide, the limitations of HHSC services, and the importance of the existing caregiver arrangement in the development of a service plan.

The service plan should reflect consideration of all these factors:

• person's existing problems that resulted in an application for CCSE services;
• person's physical and mental health;
• person's functional capacities for self-care;
• person's need for, or availability of, self-help or adaptive devices;
• existing caregivers and the specific amounts and types of assistance they give and can continue to give the person;
• person's home environment and available community resources;
• severity of the person's medical and physical problems and the level of risk the problems cause;
• other HHSC services necessary to help the person maintain self-sufficiency, including referral to Adult Protective Services when appropriate;
• additional services available in the person's community:
  • The 71st Texas Legislature passed Senate Bill 487 which requires, when appropriate to the person's needs, the use of services provided by other state agencies.
  • Review Appendix XV, Services Available from Other State Agencies.
• services provided to other people in the household;
• information secured from the person's practitioner, friends, or associates that may be necessary to develop a service plan suitable for the person's needs;
• number of service units to be authorized and the rationale for the authorization;
• dates that services are expected to begin; and
• any special monitoring or case management procedures to be followed.

Document service planning information on:

Form 2110, Community Care Intake;
Form 2059-W, Summary of Individual's Need for Service Worksheet, which is entered in the Service Authorization System for Form 2059, Summary of Client's Need for Service;
Form 2101, Authorization for Community Care Services;
Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, which is entered in the Service Authorization System.

2511 Caregiver Arrangements

Revision 24-5; Effective Nov. 1, 2024

Discuss with the person and any family members or caregivers that Community Care Services Eligibility (CCSE) services are not designed to replace the care family members and other caregivers now provide or are able and willing to provide over time. Explain that the existing caregiver arrangement is very important to the development of a service plan. If possible, confirm with the caregivers that they are able and willing to perform the tasks listed on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, which are marked C for the caregiver.

Be sure the person and family members understand that CCSE services are to serve as something other than a supplement to income. Decisions about service plans cannot be based on the family's income or financial needs.

2512 Caregiver Support

Revision 24-5; Effective Nov. 1, 2024

Caregiver support is providing relief to a caregiver who provides most of the applicant's care or continual care for the applicant. This support is always provided by an attendant other than the applicant's regular caregiver. Caregiver support may be appropriate when the initial functional assessment results in no unmet need, but the caregiver needs relief. The paid attendant will provide some of the tasks that the caregiver has been performing to give relief.

Examples: Caregiving responsibilities prevent the person's caregiver from leaving the house to conduct personal business or do the family shopping. Or, the caregiver needs time away from their caregiving duties on a regular basis due to their health needs or for periods of rest due to the continual care.

Discuss with the caregiver how many days per week and what tasks may be needed to provide relief. Mark the appropriate items on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide with a P, and document on each task in the comments section when that support care is needed. Indicate on Form 2101, Authorization for Community Care Services, that the service plan is for caregiver support and list the caregiver as someone not to be hired. Support care may be temporary. If so, authorize it only for the time needed.

Note:  The local Area Agencies on Aging provide several services designed to support caregivers. Service availability varies by region. To find out if services are available in an area, provide the toll-free phone number 800-252-9240 to persons interested in potential services.

2513 Caregiver as the Paid Attendant

Revision 24-5; Effective Nov. 1, 2024

If the caregiver expresses an interest in being the paid attendant, inform them and the applicant that the caseworker cannot recommend to the provider who to hire as the paid attendant. It is the provider's responsibility to hire an attendant. Encourage people who want a specific person to be the attendant to discuss this with provider staff. The caseworker must explain to the potential attendant that they will be an employee of a home and community support services agency. They must be able to provide the tasks needed and work the complete specified schedule the provider and the applicant develop. Their performance will be monitored and evaluated by the provider and the caseworker.

The caseworker must also explain to the applicant and the caregiver that the tasks listed as C for caregiver under the service arrangement on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, must remain as caregiver tasks if the caregiver is hired as the paid attendant. Those tasks may not be purchased tasks if this caregiver is the paid attendant. If circumstances change and the attendant can no longer perform or is no longer willing to perform either the purchased tasks or the caregiver tasks, then the provider is requested to hire a new attendant for those tasks. The caregiver will be designated as someone not to be hired for those tasks on Form 2101, Authorization for Community Care Services.

In situations as described in Section 2433, Determining Unmet Need in the Service Arrangement Column, where the caregiver has recently quit employment to provide care, note the tasks the caregiver will continue to provide voluntarily and mark them as C in the service arrangement column of Form 2060. Other needed tasks may be purchased.

For ongoing cases, a caregiver who had been listed as working full time and quit a job to provide care for the person may also be considered as a potential attendant. The caseworker must get verification that the caregiver quit employment within 30 calendar days before the requested change. Any tasks previously identified as performed by the caregiver may not be purchased tasks.

2514 Who Cannot Be Hired as the Paid Attendant

Revision 24-5; Effective Nov. 1, 2024

The Texas Health and Human Services Commission (HHSC) is not responsible for selecting and hiring the person's paid attendant. The only role HHSC plays in the hiring process is notifying the provider when a particular person must not be hired.

Based on the following chart, if a person is identified as someone who must not be hired as a paid attendant, the caseworker documents this information in the Comments section on the initial and all later submissions of Form 2101, Authorization for Community Care Services. The caseworker enters Do Not Hire and the name of the person on the form. The following chart lists the persons who must not be hired and must be specified as Do Not Hire.

Beyond these limitations, the caseworker will not specify who cannot be hired as the paid attendant.

2520 Freedom of Choice

Revision 17-1; Effective March 15, 2017

2521 Freedom of Choice in Living Arrangements

Revision 24-5; Effective Nov. 1, 2024

The applicant has freedom of choice regarding their living arrangements. However, caseworkers are required to consider if the person's needs can be met in the environment chosen by the applicant.

Consider the person's ability to understand if the services the Texas Health and Human Services Commission (HHSC) can provide are enough to meet their needs. If the person has medical needs that cannot be addressed with personal care and housekeeping services, or if the environment poses a threat to health and safety, discuss these issues with the person and the responsible person.

Explain the limitations of Community Care Services Eligibility (CCSE) services and determine how the person's needs will be met. Explore the possibility of alternative living arrangements, if feasible and necessary. If the person insists on remaining in their current residence, even though their needs may not be met in that environment, assess their mental capacity for making an informed choice and if they understand the consequences of that choice. Review Section 2550, Identifying People at Risk, for additional information.

If they are capable of giving informed consent, respect their choice and develop a service plan accordingly. If they appear incapable of making an informed choice or if abuse, neglect, or exploitation is suspected, make a referral to Adult Protective Services.

2522 Service Delivery in Alternate Locations

Revision 24-5; Effective Nov. 1, 2024

It is acceptable to allow delivery of services meant for the home environment to be given in alternate locations. Hours diverted to provide services to the person in alternate locations may not be added back into the service plan. Example: A person's service authorization includes an hour each day for feeding or eating. The person will also need this help during a visit to their sister, who lives 20 miles away, which adds an hour to the time necessary to provide this help. The person opts to divert an hour allocated for laundry to feeding or eating to make the visit. This hour cannot be added back into the service plan to provide the amount of time required to do the laundry.

Do not anticipate the need for more hours based on the delivery of services outside the home and build that time into the service plan. It is also unacceptable to approve additional hours because the extra time expenditure does not allow the attendant enough time to do some other tasks. Hours authorized are based solely on services assumed to be provided in the home.

When people receive services outside the home, providers must document in the comments section of Form 3054, Service Delivery Record, the specific services provided and in which location. Documentation must also be available to substantiate the person who requested these services. The actual transportation, as well as the transportation cost, are the responsibility of the person.

2523 Freedom of Choice in Agency Selection

Revision 24-5; Effective Nov. 1, 2024

Once the applicant looks likely to meet the eligibility criteria for Community Care Services Eligibility (CCSE) services, offer the applicant the choice of selecting an agency contracted to deliver the requested service in the applicant's area. Either the applicant or the responsible person may make the selection. The selection must be documented on an agency choice list or other document in the case record.

If the applicant requests time to consider their choice or to consult with family members or other resources, leave the applicant a return envelope. You can also arrange to pick up the agency choice list when the decision is made.

If the applicant refuses to choose from all the contracted agencies in the service area, an agency may be selected for the applicant as a last resort. The selection is assigned from a regional agency rotation log, which must be maintained and kept up to date.

2530 Other Resource Services

Revision 24-3; Effective July 1, 2024

When determining unmet need, identify and examine the services of other agencies' that the person receives or is eligible to receive. This prevents service duplication and ensures all service resources are pursued. Refer to Appendix XV, Services Available from Other State Agencies, for information about services that may benefit the person. Document the use of other service resources on Form 2059-W, Summary of Individual's Need for Service Worksheet, Item 7.  Document information about other service resources in the Service Authorization System Online (SASO) Support Assisting Client window.

All other services available to the person must be considered and used before services are authorized by the Texas Health and Human Services Commission (HHSC).

2531 Veterans Affairs Aid and Attendance and Housebound Benefits

Revision 24-5; Effective Nov. 1, 2024

Some people receive Aid and Attendance (A&A) or housebound benefits (HB) from Veterans Affairs (VA). These benefits must be considered the primary source of funds to pay for in-home services.

HHSC has an information sharing program between HHSC, the Texas Veterans Commission (TVC), and the Veterans Land Board (VLB) to coordinate and collect information about the use and analysis among state agencies of data received from the Public Assistance Reporting Information System (PARIS) VA match. The PARIS system is a federal-state partnership that provides states with detailed information and data to help maintain program integrity and detect improper payments.

This information-sharing program helps identify HHSC recipients who may be eligible for veteran’s benefits. HHSC creates a file of active recipients in the Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF), and Medicaid programs. The file of active recipients is sent to the Defense Manpower Data Center (DMDC) on a quarterly basis for PARIS matching. DMDC returns a file of the matched recipients with veterans’ benefit information back to HHSC. This file is shared with the TVC and VLB to contact veterans who may be eligible for benefits or may be eligible for increased benefits and report those benefits back to HHSC.

HHSC will receive reports about A&A and HB that may affect the level of service currently authorized for personal attendant services (PAS).  HHSC will verify the information on any people currently receiving Community Attendant Services (CAS), Primary Home Care (PHC), Family Care (FC), Home and Community-based Services (HCS), Community Living Assistance and Support Services (CLASS), Deaf Blind with Multiple Disabilities (DBMD), Texas Home Living (TxHmL), or STAR+PLUS Home and Community Based Services (HCBS) programs. Since financial eligibility for CAS is determined by HHSC, any changes to eligibility status will be processed by HHSC.

Actions Required Upon Receipt of the Report

When the report is received, the region must distribute the information to the assigned caseworkers so they can contact the person and verify the change in VA benefits. For people receiving A&A or HB, the caseworker must discuss and document how the person is using the benefits. A list of some of the items or services that can be purchased using A&A or HB funds includes:

• medical supplies;
• medical equipment;
• nursing services;
• therapy;
• skilled services;
• medications; or
• other medically necessary items.

If all the A&A or HB funds are being used to purchase items that help the person remain independent and in the community, the caseworker documents the information, and no funds are applied to the service plan.

The person may also use the funds to purchase:

• PAS; or
• home health aide services.

If the person is using the funds to purchase PAS or home health aide services, this must be considered when developing the plan of care. For FC, PHC, and CAS, note this on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, as services delivered by another agency. If the person can purchase all the services required, then there is no unmet need, and the person is not eligible for PAS. If the person can only purchase part of the necessary services, or if the funds are not used to purchase services, then the amount of the A&A or HB funds is applied to the purchase of attendant care per Form 2060 instructions.

If the funds are not used to purchase services that help the person remain independent and in the community, apply the funds to the purchase of non-skilled attendant care. Calculate the number of hours of non-skilled attendant care that could be paid for with the person's unused portion of A&A or HB. To do this, divide the unused portion of the monthly benefit by the maximum non-priority attendant care limit rate without regard to the service authorized. If the person meets the priority status criteria, use the maximum priority status attendant care limit rate. Subtract the resulting amount from the person's authorization. If the number of hours required by the person's unmet need is more than the benefits they can purchase, authorize the additional needed hours of PAS. Begin these calculations by using the actual number of hours required by the person's unmet need, even if this exceeds the maximum HHSC can purchase.

These procedures apply only to the purchase of PAS. Do not reduce the amount of other services because the person receives VA benefits.

Example: A person whose unmet need requires 20 hours per week of PHC receives A&A benefits. Dividing the amount of this person's A&A benefits by the current maximum attendant care limit rate yields 46 hours per month.

46 ÷ 4.33 = 10.6 hours per week

20 − 10.6 = 9.4 hours per week

This person may be authorized 9 1/2 hours per week.

Explain this procedure to the person. If the authorized hours cannot cover all of the purchased tasks that have been identified on Form 2060, then the person and caseworker should jointly decide which PAS tasks will be purchased and authorize only those tasks on Form 2101, Authorization for Community Care Services. Update the Service Arrangement Column of Form 2060 to match the tasks/hours authorized on Form 2101.

Reporting Requirements

Regional management will be required to report the savings generated by the application of VA funds. Example: A person requires 20 hours per week of PAS but is now receiving A&A funds. The A&A funds can purchase five hours per week, reducing the weekly service plan to 15 authorized hours per week. The cost of the five hours per week is reported as a savings for HHSC.

2532 Skilled Home Health Services

Revision 24-5; Effective Nov. 1, 2024

If a person is receiving or is eligible to receive Medicare or Medicaid skilled home health (SHH) attendant care services, the tasks provided or potentially provided must be considered as resources available to the person when determining unmet need. SHH is ordered for a person by their physician and is provided over a short period of time in conjunction with illness.

Use regional procedures to refer any applicant or person who requests or appears in need of SHH services.

It is possible to authorize other Community Care Services Eligibility (CCSE) services, including personal attendant services (PAS), at the same time SHH attendant care is being used. Both services may even be provided on the same day. If a person is receiving SHH attendant care, determine exactly which services are being delivered and ensure they will not be duplicated by any CCSE service that the person may need. If SHH provided attendant care on some but not all the days of a week, PAS may be authorized to provide attendant care on the other days, if needed. If SHH is providing all the personal care needed by the person but housekeeping services are needed, Family Care or Home-Delivered Meals may be suitable options to consider.

If SHH is providing only skilled nursing services by a registered nurse or licensed vocational nurse, the service would be unique from any other CCSE service that might be authorized and is not a consideration to determine unmet need. Consider how long SHH has been in use and how long it will continue as the CCSE service plan is developed with the person. If duplication of tasks would occur by authorizing a CCSE service, denial or a later revision to the service plan may be necessary.

2533 Hospice Services

Revision 24-3; Effective July 1, 2024

Medicaid recipients waive their rights to other programs with Medicaid services related to treatment of the terminal illness(es) when they elect the Medicaid Hospice Program. These waived services are limited to services also provided under Medicare. Recipients do not waive their rights to HHSC services unrelated to the treatment of the terminal illness(es). Therefore, participation of the person in a hospice program does not affect eligibility for Community Care Services Eligibility (CCSE) programs.

If a person chooses to receive hospice services and some of their needs will not be adequately met by the hospice agency, assess the person and authorize services for their remaining needs on the same basis as any other person.

Review Section 2745, People Who Need Hospice Services for more detailed information about the Hospice program.

2534 Mutually Exclusive Services

Revision 24-3; Effective July 1, 2024

Ask the person or family members if the person is receiving another HHSC service to determine:

• unmet need for a particular Community Care Services Eligibility (CCSE) service; or
• if a person can receive other HHSC services.

Check the Service Authorization System Online (SASO) and Texas Integrated Eligibility Redesign System (TIERS)  for services and refer to Appendix XX, Mutually Exclusive Services. Review Section 4000, Specific CCSE services.

2534.1 Services Through the Texas Home Living Waiver

Revision 24-5; Effective Nov. 1, 2024

Due to the limited services provided through the Texas Home Living (TxHmL) waiver, some Community Care Services Eligibility (CCSE) services are not mutually exclusive and can be received at the same time as Texas Home Living (TxHmL). Review Appendix XX, Mutually Exclusive Services.

Caseworkers must review the services received through TxHmL before authorizing CCSE services. This is to ensure there is no duplication of tasks and there is an unmet need for the service. People must meet the eligibility requirements for the specific CCSE service requested. The caseworker must document there is no duplication.

2534.2 Targeted Case Management and Other HHSC Services or the STAR+PLUS Program

Revision 25-2; Effective March 31, 2025

Local Authorities (LAs) provide service coordination through Targeted Case Management (TCM) to people with Intellectual and Developmental Disabilities (IDD) in the HHSC LA priority population.

TCM authorizations are processed through the Service Authorization System Online (SASO). TCM services are identified in SASO as Service Group 14, Service Code 12A or 12C. TCM can be authorized along with Home and Community-based Services (HCS), Texas Home Living (TxHmL) or as a general revenue (GR) service.

TCM and Other HHSC Services

Other HHSC waiver services excluding HCS and TxHmL are mutually exclusive with TCM. A person receiving any of the following waiver programs cannot receive TCM at the same time:

• Community Living Assistance and Support Services (CLASS)
• Deaf Blind with Multiple Disabilities (DBMD) Waiver

If a person on TCM is applying for one of these waivers, then the SASO Service Codes 40, 40A and 60, for assessments, pre-assessments and prescriptions, are the only service codes allowed to overlap with TCM service authorizations.

Since the waiver programs identified above provide more comprehensive services to the person, they will take precedence over TCM services to maximize the benefit to the person. The HHSC caseworker must contact the LA to coordinate closing TCM for the waiver service to begin. People receiving the STAR+PLUS program may receive TCM. These services are not mutually exclusive.

The Program for All-Inclusive Care for the Elderly (PACE) is not a waiver program but an all-inclusive program. PACE is mutually exclusive with all other services including TCM. Review Appendix XX, Mutually Exclusive Services.

TCM and Other HHSC Services

Determine if a person who receives TCM services can receive other HHSC services, including Community Care Services Eligibility (CCSE) services. This depends on if they are receiving TCM services through HCS, TxHmL or as a GR service.

Once the caseworker identifies a person is receiving TCM, they or a regional designee must check the Client Assignment and Registration (CARE) system to determine if the person is receiving HCS or TxHmL. If the person is receiving HCS or TxHmL, the caseworker must refer to Appendix XX, to determine if the person can receive other HHSC services, as some services are mutually exclusive, and others are not.

If the person is receiving HCS or TxHmL and the requested CCSE service is mutually exclusive, then the caseworker contacts the person to allow a choice of services and document the person's choice. If the person elects to continue receiving HCS or TxHmL, then the request for CCSE services is denied. If the person elects to receive the CCSE service, then the caseworker must contact the LA to coordinate closing services.

If the person is not receiving HCS or TxHmL and is receiving TCM as a GR service, then they can receive other CCSE services.

2535 Involvement of Volunteer Resources

Revision 24-5; Effective Nov. 1, 2024

Volunteers may perform some services needed by people who are older and people with disabilities. When developing a person's service plan, consider if volunteers from community resources might meet some of the person's needs.

Volunteer help may include:

• shopping and paying bills;
• transportation;
• phone reassurance;
• friendly visits;
• recreation activities, such as reading aloud, games, help with sewing, knitting, art, or other handwork; or
• writing letters.

Some organizations may contribute group volunteer efforts to accomplish significant tasks for people with functional disabilities. These tasks might include:

• clothing care and distribution;
• yard work;
• hauling trash;
• cleaning windows;
• critical home repair;
• construction of ramps and assistive devices in the house;
• provision of medical equipment or apparatus;
• facilitation of support groups for caregivers; and
• transportation for older people and people with disabilities who are shut ins.

Before finalizing a plan that involves volunteers, it's important to have a thorough discussion with the individual and their family or caregiver. If a person's needs are fully met through planned volunteer services, the case can be kept open as Case Management only. This means that the person's condition necessitates regular monitoring, but their needs are being met through volunteers. It's crucial to document all aspects of volunteer resources and their use.

2536 Program of All-Inclusive Care for the Elderly

Revision 25-2; Effective March 31, 2025

The Program of All-Inclusive Care for the Elderly (PACE) is an all-inclusive program that provides all required services for a person enrolled in the program.

PACE services are available in designated areas of El Paso, Lubbock, and Amarillo and Canyon.

PACE Referral

Texas Health and Human Services Commission (HHSC) intake screeners in the catchment areas must be aware of the PACE service and referral procedures for the service. Intake screeners must provide information about PACE to people during the intake and referral process when the person requesting services is determined to be 55 years or older and lives in a PACE service area. People in the PACE catchment areas may request services through the local HHSC intake office or the PACE service site.

• Bienvivir Senior Health Services has two sites in El Paso that provide PACE services to participants. Contact the Intake Department at Bienvivir Senior Health Services by phone at 915-562-3444 for potential participant referrals.
• The Basics at Jan Werner has a site in Amarillo that provides PACE services to participants. Contact The Basics at Jan Werner by phone at 806-374-5516 for referrals of potential participants.
• Silverstar has a site in Lubbock that provides PACE services to participants. Contact Silverstar phone at 806-740-1500 for referrals of potential participants,

PACE Eligibility

To be eligible for PACE, the person must:

• be 55 and older;
• be certified as nursing home eligible;
• meet medical necessity criteria for nursing facility care;
• choose PACE services; and
• live in a designated catchment area.

PACE Services

The PACE interdisciplinary team provides preventative, rehabilitative, curative, and supportive services in day health centers, homes, hospitals and nursing homes. Required services include all Medicare and Medicaid covered services and any other services the multidisciplinary team identifies as needed.

The PACE Integrated Model of Care includes any health-related service needed, including but not limited to:

• in-home services;
• day health care;
• primary care;
• acute hospital care;
• lab, x-ray, and ambulance services;
• skilled nursing facility care;
• medical specialty services;
• all in-patient and out-patient medical care;
• specialty services such as dentistry and podiatry;
• social services;
• meals; and
• transportation.

Since PACE is an all-inclusive program, it is mutually exclusive with all other HHSC programs and STAR+PLUS programs. Review Appendix XX, Mutually Exclusive Services.

2540 Priority Status

Revision 23-1; Effective March 1, 2023

A recipient priority status is assigned if an applicant or recipient cannot perform one or more of the following ‘priority tasks’ without hands-on help from another person:

• feeding;
• eating;
• toileting;
• transfer; or
• meal preparation. 

Assign priority status if at least one priority task is purchased and the recipient's:

• functional score for that task is 3; and
• support score for that task is 4.

Complete the service arrangement column on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide for each task where the recipient’s impairment score is 1, 2 or 3. Complete the support score column for each priority tasks where the recipient scores 3 and the service is being purchased.

If the attendant does not show up during a normally scheduled service shift, the recipient's health, safety or well-being may or may not be jeopardized. Always assess the potential impact on the recipient's health, safety or well-being when determining the effects of an attendant not providing service.

Do not designate a recipient as having priority status if the failure of the attendant to report to work would not result in any risk to the recipient's health, safety or well-being. If the recipient appears to be at risk (scores a 3 on a priority task with little or no caregiver support), document the reason(s) why a support score of 4 was not assigned.

In determining if health, safety or well-being is endangered, consider the worst result that might follow from the attendant not providing service.

Example: A recipient may have a friend who visits daily when they can, but the friend is regularly out of town on business. Determine the consequences of the attendant not showing up on a day when the recipient's friend is out of town.

Consider each recipient's condition and situation. One recipient may be able to miss a meal during a scheduled service shift because their caregiver will be home later to prepare the meal. Another recipient may not be able to miss a scheduled meal without risk to their health because of their nutritional needs or no caregiver to prepare the meal later. Contact the regional nurse if help is needed in assessing the risk that would result from an attendant not working during a scheduled shift.

Advise priority recipients of:

• the importance of being available in their homes during the hours designated in the service plan; and
• to contact the provider in advance if the recipient knows they will not be at home during a normally scheduled shift. 

If information is received that a priority recipient will not be home, inform the provider.

Inform a priority recipient that the provider may monitor the attendant's work performance by making frequent calls or home visits. If a priority recipient objects to this increased monitoring of the attendant, the recipient has the option of withdrawing from priority status.

For priority cases, note in the comments section of Form 2101, Authorization for Community Care Services, this is a priority case. Use verbal referral procedures for new priority recipients negotiated with the provider.

Providers may not allow a service interruption for a recipient designated as priority status unless the:

• service interruption is caused by suspension of services;
• recipient is not at home when the attendant is scheduled to provide services; or
• recipient requests that services not be provided on specific days.

The provider must notify CCSE staff within seven calendar days of a priority recipient not receiving scheduled services. This notification is for CCSE staff's information only. No response is required. Do not approve or disapprove service interruptions for priority recipients.

Recipients can refuse priority status. If a recipient refuses priority status, document in the case record the recipient's decision and the reason for it.

Because the unit rate for priority recipients is higher than the rate for non-priority, the maximum allowable service authorization is less for priority recipients. A priority recipient receiving the maximum hours per week may not be able to receive another Community Care Services Eligibility service for which they may be eligible. This could exceed the total expenditures allowed by the average daily nursing facility rate. A priority recipient can exercise the option to receive less than the maximum hours to receive another needed service or they can decline priority status. CCSE staff must give the recipient the choice and explain the options, including the advantages or disadvantages of each. Document the recipient's decision in the case record.

Related Policy 

Support Score and Establishing Priority, 2434
Negotiated Referrals, 2631
Priority Status Determination, 4624
Suspension of Services and Interdisciplinary Team Procedures, 4677
Cost Limit for Purchased Services, Appendix II

2550 Identifying People at Risk

Revision 24-5; Effective Nov.1, 2024

A person whose unmet medical or functional need constitutes a potential hazard to their health or safety may need individualized case management and monitoring procedures to minimize immediate dangers and to prevent deterioration of their condition. The caseworker may identify the unique problems of these people at the time of assessment and reassessment, or regional nurses may note them during utilization review visits. Provider staff may also alert the caseworker. Address these problems in the person's service plan and document the information on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, or on Form 2059-W, Summary of Individual's Need for Service Worksheet. This information is entered into Form 2059, Summary of Client's Need for Service, in the Service Authorization System. Consult with the unit supervisor and the regional nurse about threats to the person's health and safety and about unmet medical and functional need issues. Use a team approach to develop service and monitoring plans whenever necessary and feasible.

A critical level of risk exists when a person has specific medical, physical, and social characteristics that endanger their health and safety in current living arrangement. Factors that contribute to critical risk are the person's level of functional impairment, their medical condition, the quality and strength of their caregiver arrangement, and the physical and social conditions of their immediate environment.

The following characteristics are indicators of potential critical-risk situations. If two or more of these are present in a person or in their situation, the caseworker must decide if they should be handled as a person at risk.

• The person has a score of 40 or higher on Form 2060.
• No caregiver is available to provide needed assistance, or the person's caregiver may:
  • be unable or unwilling to provide the necessary care; or
  • exhibit abusive, neglectful behavior.
• The person may not have sufficient mental clarity to make an informed choice and understand the consequences of that choice (scores of 2 or 3 on Item 23, Form 2060).
• The person may be immobile or nonambulatory or may need total assistance with feeding, toileting, or medication and exhibit an inability to maintain their safety.
• The person may have complex health problems that create the need for skilled nursing assistance with personal care tasks, specialized technical skills in daily management of personal care, or total assistance with several personal care tasks.
• The person's home may need to be improved to provide a safe environment.

Document the critical-risk decision and the reasons for it on Form 2084, Risk Management Team Meeting Summary. 

2551 Caseworker Actions for People at Risk

Revision 24-5; Effective Nov. 1, 2024

The caseworker must discuss the person's needs and the critical conditions with the unit supervisor and any other person who may have identified the problems. The caseworker and unit supervisor determine if a risk management team meeting is necessary. If necessary, the caseworker will:

• Organize and coordinate a team meeting. Include the provider supervisor, the unit supervisor and the regional nurse. If the situation indicates possible abuse, neglect, or exploitation, report this to Adult Protective Services staff at the Department of Family and Protective Services.
• Discuss with the team the specific circumstances that place the person at risk, the options for dealing with those circumstances, and the person's capacity to consent. Determine if a team visit to the person's home is necessary.
• Discuss and agree on how often and by whom monitoring contacts will be made. Document the monitoring plan per regional requirements.
• Use information from team members and document the person’s circumstances or condition on Form 2084, Risk Management Team Meeting Summary. Have available team members sign the form. Keep the original in the case record and provide copies to team members.
• Coordinate the team visit to the person's home, if necessary.  All team members may not need to attend.  Discuss with the person, their family, and caregivers:
  • specific circumstances that place the person at risk;
  • options for dealing with those circumstances;
  • the proposed monitoring plan; and
  • the limitations of Community Care Services Eligibility (CCSE) services.
• Discuss Attachment 2307-A, Family Care, Community Attendant Services and Primary Home Care Rights and Responsibilities, with the person, their family members, and caregivers. Make sure they understand the proposed service plan and the limitations of CCSE services. Review Form 2307, Rights and Responsibilities, with the person, family member or caregiver. The caseworker must sign the form and file it in the case record.
• Monitor the person per the monitoring plan, documenting contacts until the circumstances or problems that caused the person to be at critical risk are as stabilized as possible or until the person's circumstances or degree of risk changes. Coordinate monitoring contacts with provider staff and with the regional nurse.
• Conduct functional reassessments every 12 months, or more often if needed, depending on the person's situation or as indicated in the monitoring plan.

If the team members disagree about whether a person is at risk, the person who first identified the critical risk indicators should document the following:

• person's situation that puts them at risk;
• notification of other appropriate parties, including the caseworker's supervisor; and
• responses to the notification.

If service plan disagreements cannot be resolved through team discussions, the unit supervisor consults with the lead regional nurse and, if necessary, the program director. Any difficulties with providers that cannot be resolved through discussion should be reported to the contract manager. If the problem cannot be resolved during the discussion process, the regional director will make the final decision.

If, during the service planning process, staff become aware the person's mental and physical health needs are not likely to be adequately met by authorized HHSC services, inform the person and their family about alternative living arrangements and nursing home care, if appropriate. Document this conference and the person's response on Form 2084. The person and their family decide if they are to remain in their present living arrangement, using the available services. The person is free to refuse any or all services offered.

2610 Application Processing and Notification

Revision 25-4; Effective Sept. 1, 2025

Eligibility for CCSE services for income-eligible applicants is determined within 30 calendar days after a signed application is received. For categorically eligible applicants, the eligibility determination process begins within 30 calendar days after the person’s assessment with CCSE staff. This process involves a thorough assessment of the applicant's circumstances and needs.

No further action is necessary if the person withdraws the request for services before the assessment is started or completed, an application is received or a face-to-face home visit is made.

Related Policy

26 Texas Administrative Code Section 271.151(d) 
Categorical Eligibility, 2341.3 
Income and Income Eligibles, 3310

2611 Processing Time Frames

Revision 24-5; Effective Nov. 1, 2024

Program Standard: The caseworker is required to determine eligibility for Community Care Services Eligibility (CCSE) services for income-eligible applicants as soon as possible, but within 30 calendar days after a signed application is received. The caseworker must determine eligibility for categorically eligible applicants as quickly as possible but within 30 calendar days after either the person's assessment or face-to-face contact with the caseworker, whichever occurs first.

Note: Eligibility for Home Delivered Meals (HDM), which does not require financial determination, must be determined within 30 calendar days from their assessment date.

This standard is applied to all applications, except for Community Attendant Services (CAS), using the date shown as the Date Eligibility Rules Processed  on the Service Authorization System Online Wizards (SASOW) Form 2064, Eligibility Worksheet as the end point of measurement. The 30 calendar day processing deadline cannot be used to delay a decision if all information is available before the 30th calendar day.

Proceed with the eligibility determination process if the person fails to cooperate but has received facility-initiated Day Activity and Health Services (DAHS) when the person is receiving Medicaid benefits.  Review the procedures in Section 4231.2, Intake Response.

2611.1 Processing Time Frames for Community Attendant Services

Revision 24-5; Effective Nov. 1, 2024

Applications for Community Attendant Services (CAS) must be referred to Medicaid for the Elderly and People with Disabilities (MEPD) staff for a financial eligibility determination. The MEPD process may delay Community Care Services Eligibility (CCSE) certification beyond the 30 calendar day time frame.

MEPD may notify the Texas Health and Human Services Commission (HHSC) caseworker of the eligibility decision through the MEPD to HHS Communication Tool.  If a decision is not received, the HHSC staff person must check the Texas Integrated and Eligibility Redesign System (TIERS) for an MEPD eligibility decision on or before the 25th calendar day from the application date and perform weekly checks until the financial eligibility decision is received. The TIERS checks must be documented.

When the financial eligibility decision notification is received either through TIERS or the MEPD to HHS Communication Tool, the caseworker has seven business days to:

• complete data entry in the Service Authorization System Online Wizards (SASOW); and
• send the referral packet to the Home and Community Support Services Agency (HCSSA) to begin pre-initiation activities.

The seven business days are measured from the date HHSC receives the eligibility decision from MEPD or the date eligibility is verified through TIERS. The caseworker must print a copy of the financial eligibility notice or TIERS screen and file it in the case record.

The HHSC caseworker must advise MEPD only if the applicant is not approved for CAS,  that is, no practitioner’s statement or other circumstances preventing services deliver. In this circumstance, the caseworker must send Form H1746-A, MEPD Referral Cover Sheet, to MEPD within two business days of determining the person is not eligible for CAS, advising that the applicant has not met the functional eligibility requirements. Form H1746-A is sent to MEPD at the same time Form 2065-A, Notification of Community Care Services, is sent to the person notifying them of CAS ineligibility.

The caseworker is not required to notify MEPD when CAS services are authorized.

Review Section 4653, Referral to the Provider, and Section 4660, Service Authorization, for more procedures for authorizing CAS services.

Caseworkers always have seven business days after confirmation of MEPD eligibility to send the referral to the provider. This applies even when verification of MEPD certification is received near the end of the 30 calendar day period allowed for completing CCSE applications.

2612 Notification of Eligibility Decision

Revision 24-5; Effective Nov. 1, 2024

An applicant or person certified for one Community Care Services Eligibility (CCSE) service but determined ineligible for another must be notified in writing of both decisions. An applicant or person certified for Personal Attendant Services (PAS) or Home-Delivered Meals (HDM) must also be notified in writing of the service units per week they are eligible to receive. If certified for Day Activity and Health Services (DAHS), the applicant or person must be notified in writing of the number of days per week the DAHS authorization covers. The written notice for all services must contain the caseworker's name, phone number and appeal procedures.

When notifying the applicant of eligibility, specify on Form 2065-A, Notification of Community Care Services:

• the CCSE services for which the applicant is eligible or ineligible; and
• if determined eligible:
  • the number of hours of services the applicant is authorized to receive or the number of days or half days the applicant is authorized to attend a DAHS facility;
  • if applicable, that the Family Care, Community Attendant Services or Primary Home Care applicant is eligible for priority status; and
  • the initial and ongoing copayments the person is to pay to the Residential Care facility.

The caseworker may notify a person verbally of continued eligibility if the person continues to qualify for the same service(s) and the number of hours or units of service remains the same.

Review Section 2662, Redetermination of Financial Eligibility, and Section 2660, Reassessments and Recertification Procedures, for time limits that apply when eligibility is redetermined.

2613 Case Record Documentation

Revision 24-4; Effective Sept. 1, 2024

To document the eligibility decision, the applicant’s case record must contain dated copies from Service Authorization System Online (SASO) of the following forms:

• Form 2064, Eligibility Worksheet, except if;
  • the application is denied before a financial eligibility determination is made; and
• Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, except if the;
  • applicant requested only Day Activity and Health Services (DAHS), which does not require a Form 2060 score;
  • applicant withdrew the application before the caseworker completed Form 2060;
  • application is denied for a reason other than:
    • no unmet need;
    • insufficient functional impairment; or
    • low hours for Family Care or Primary Home Care.

Note: Ensure each person enrolled in a Title XX program who is not categorically financially eligible receives a privacy notice, Form 0401, Notice of Privacy Practices or Form 0403, Explanation to Health Information Privacy Rights, as appropriate.

Related Policy

Privacy Notice, 1147

2620 Service Authorizations

Revision 24-5; Effective Nov. 1, 2024

After developing the service plan with an eligible person, enter information in the Service Authorization System Online Wizards (SASOW) to authorize services.

Service plans may include one or more purchased services. If authorizing more than one service, ensure the tasks are not duplicative, and the service combinations are within the allowable costs specified in Appendix II, Cost Limit for Purchased Services.

Example: Before authorizing ten units of Day Activity and Health Services (DAHS) per week for a person who will also be receiving an in-home service, determine if it is feasible for the person to take part in DAHS five full days per week.

Based on the urgency of the person’s need, negotiate with the provider for the earliest possible date that services can begin. Remember that services can and may need to start on the weekend if a person is discharging from a hospital or other institution on a Friday afternoon and needs services immediately. Enter the negotiated beginning date of coverage.

Use the comments section of Form 2101, Authorization for Community Care Services, to give specific instructions to the provider about the person’s service arrangement. These include the number of days the person requests services, specific service schedules required or strongly preferred by the person, specific instructions about unique personal problems or the person’s home, or information about people who should not be hired as the paid attendant.

For all personal attendant services (PAS), send the provider the initial packet, which must include a cover sheet, the Long-term Care Services Intake System (NTK) generated Form 2110, Community Care Intake, and a copy of the following SASOW generated forms:

• Form 2059, Summary of Client’s Need for Service;
• Provider Referral Supplement;
• Form 2060, Needs Assessment Questionnaire and Task/Hour Guide;
• Task/Hour Guide; and
• Form 2101, Authorization for Community Care Services.

Note: In the SASOW, the following forms are generated as two forms:

• Form 2059 is generated as Form 2059 and the Provider Referral Supplement.
• Form 2060 is generated as Form 2060 and the Task/Hour Guide.

For Family Care, Form 2101 is an authorization to begin services.

For CAS and PHC, Form 2101 is a referral, and authorization for services is left pending receipt of Form 3052, Practitioner’s Statement of Medical Need.

Providers must follow the instructions on Form 2101. If a provider does not, try to resolve the problem through discussion with the provider’s supervisors. If this fails, document and report the issue to your supervisor and follow the procedures specified in Section 2700, Service Monitoring, Changes, and Transfers.

Related Policy

Content of Referral Packets, Appendix XIII

2630 Referrals to the Provider

Revision 17-1; Effective March 15, 2017

Refer to Section 4000, Specific CCSE Services, for specific procedures for each service for sending referrals to providers. See Appendix XIII, Content of Referral Packets, for referral-packet contents sent to providers for each service.

2631 Negotiated Referrals

Revision 24-5; Effective Nov. 1, 2024

Program Standard: People must be referred by the next business day after the day the person is visited and it is determined that a negotiated verbal referral is necessary. Form 2101, Authorization for Community Care Services, must be sent within five business days from the date the person was determined eligible for a negotiated verbal referral. Use the comment section of the form to document verbal referrals, dates and other relevant information. The caseworker must document the date Form 2101 was sent to the provider or include the fax confirmation.

Regardless of the response criteria established for the applicant at intake, the caseworker must reassess the person's need for service initiation during the assessment process. Specifically, assess the continued provision of any assistance with the person's personal care needs by people or other providers.

If it is determined that the person's unmet needs for personal care are, or will be, such that services must begin sooner than the time usually required when using the routine written referral process, contact the provider and negotiate a start date per the person's need for service initiation. The need for a verbal referral will vary from person to person. Consult with the unit supervisor if a person's particular circumstances are such that it is uncertain whether to use the negotiated referral process.

2632 Routine Referrals

Revision 24-5; Effective Nov. 1, 2024

Program Standard: For applicants who do not require negotiated referrals, authorize services by sending Form 2101, Authorization for Community Care Services, within five business days from the date the applicant is determined eligible. The caseworker must document date Form 2101 was sent to the provider or include the fax confirmation.

For services other than Day Activity and Health Services (DAHS), Community Attendant Services (CAS) and Primary Home Care (PHC), the provider must return Form 2101 by the 21st calendar day from the date of the referral. If Form 2101 or some other kind of notification is not received, contact the provider to find out the reason for the delay and the status of the referral.

If the provider is unable or fails to provide services within the 21-calendar day time frame, the caseworker may contact the person to discuss a possible referral to a different provider agency. 

Review Section 4000, Specific CCSE Services for special referral procedures for PHC, CAS and DAHS.

2640 Provider Requirements for Hiring a Paid Attendant

Revision 24-5; Effective Nov. 1, 2024

Criminal background checks are required for all facilities and service providers who provide care to older people and people with disabilities. Except in emergency situations, providers are required to get a criminal history check before offering permanent employment to unlicensed employees having direct contact with recipients who receive:

• Day Activity and Health Services;
• Residential Care;
• Primary Home Care;
• Community Attendant Services;
• Family Care;
• Adult Foster Care; or
• Consumer Managed Personal Attendant Services.

A person must be barred from employment if they have been convicted of a criminal offense where an administrative review is not available. A person may request an administrative review for some criminal offenses that could bar employment.

If asked by anyone, including the recipient, about the results of the criminal history check, explain that:

• all providers must conduct criminal history checks on attendants;
• the Texas Health and Human Services Commission (HHSC) is monitoring compliance with the law; and
• confidentiality requirements prevent the sharing of information obtained because of a criminal history check with anyone except the employee.

2650 Changes in Service Plans

Revision 17-1; Effective March 15, 2017

2651 Disagreements about Service Plans

Revision 24-5; Effective Nov. 1, 2024

If a disagreement arises between provider staff and Texas Health and Human Services Commission (HHSC) staff about a person's service plan, resolve the problem through discussion and negotiation. Use an interdisciplinary team meeting (IDT) if necessary. Ensure that services are not delayed unnecessarily because of these disagreements.

HHSC regional nurses make final decisions in disagreements with providers about a person's medical need for Community Attendant Services and Day Activity and Health Services.

In all other cases, the Community Care Services Eligibility (CCSE) supervisor attempts to resolve the disagreement with the provider's supervisor. If the supervisory staff of both providers cannot resolve the disagreement, the CCSE program manager resolves the disagreement.

2652 Changing the Service Schedule Between Reassessments

Revision 25-3; Effective June 1, 2025

Use the chart below to determine which changes must be included on Form 2101, Authorization for Community Care Services, if a schedule change results in a change in hours or priority status.

For decreases if the last day of any period is a Saturday, Sunday or legal holiday, the period is extended to include the next day that is not a Saturday, Sunday or legal holiday. Skeleton crew days are not legal holidays. Legal holidays are days when the agency is closed.

Example: Form 2065A is being sent Aug. 5 to notify a person of a decrease in hours. The 12th day of adverse action would be Aug. 17, which falls on a Saturday. The effective date on Form 2065A and Form 2101 would be Aug. 20 as the person has through the end of the business day, Aug. 19, to file an appeal.

Complete Form 2067, Case Information, for personal attendant services for all other changes not related to a change in hours.

Related Policy

Form 2101 Coverage Dates for Title XIX Services, Appendix XXIII

2653 Provider Flexibility

Revision 25-2; Effective March 31, 2025

Providers should follow instructions given on Form 2101, Authorization for Community Care Services, as much as possible. There may be times when changes in tasks or schedules are necessary to meet the person's needs. In these situations, the provider doesn’t need to notify the caseworker as long as the units delivered and billed for a calendar month are at most 4.33 times the adjusted weekly hours identified on Form 2060, Needs Assessment Questionnaire and Task or Hour Guide.

Example: A person who regularly receives 15 hours of service per week is sick for two days and declines services due to illness. During those two days, a total of five hours of personal care services would have been delivered had the person been able to receive services. Because the person may have an increased need for services following the illness, those five hours may be made up if it would be to the benefit of the person. Because the number of hours delivered does not exceed the number of hours authorized, the provider does not need to notify the caseworker.

This ongoing flexibility is to allow services to meet the person's needs, considering their desires and changes in their condition. The flexibility is not intended to be for the convenience of the provider or to be applied retroactively to justify an attendant absence or interruption of services.

If a provider makes changes to tasks or schedules inappropriately or against the person's wishes, try to resolve the issue through discussions with a provider supervisor. If this fails, report the issue to the caseworker's supervisor and follow procedures specified in 2700, Service Monitoring, Changes and Transfers.

2660 Reassessments and Recertification Procedures

Revision 24-5; Effective Nov. 1, 2024

Conduct reassessments within:

• 24 months of the previous financial redetermination; and
• 12 months of the previous functional assessment.

Annual reassessments are required for all CCSE services. Review Section 2663.1, Annual Home Visit Required for People Receiving PAS, and Section 2663.2, Determining When a Home Visit is Necessary for Other Services, to determine if a home visit is required for the reassessment.

When the reassessment is conducted in the person's home, the caseworker must schedule the visit with the person or their authorized representative at a time that is convenient to the person. Schedule the appointment by phone or in writing using Form 2068, Application, Redetermination or Monitoring for Community Care Services. If the appointment cannot be kept for some reason, inform the person or their authorized representative in advance that the appointment needs to be rescheduled. Only visit the person with advance notice of the visit.

During the reassessment, the caseworker must:

• redetermine functional eligibility on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, as required by the specific program;
• redetermine unmet need, as outlined in Section 2433, Determining Unmet Need in the Service Arrangement Column;
• review Form 2307, Rights and Responsibilities and all applicable attachments;
• present the Consumer Directed Services (CDS) option and review Form 1581, Consumer Directed Services (CDS) Option Overview. Review Section 6333.1, Authorizing CDS for Ongoing People and Section 6333.2 Transfers and Consumer Directed Services (CDS); and
• present form VR30, Texas Voter Registration Application, and offer the opportunity to register to vote.

To comply with the National Voter Registration Act of 1993, the person must be offered the opportunity to register to vote at the time of application and at each annual redetermination. Help any person who requests assistance in completing form VR30, and review form VR30 for completeness in the person's presence. The person may:

• mail form VR30; or
• return the form to the caseworker's office for appropriate mailing to the county registrar's office.

2661 Person Unavailable for Reassessment

Revision 24-5; Effective Nov. 1, 2024

In some situations, the caseworker uses their judgment to determine how long a case should remain open when the person is unavailable for a reassessment. Generally, if the person continues to be unavailable for more than 30 calendar days, it should be determined if the unavailability is temporary. If a person is repeatedly unavailable after an appointment has been scheduled, refer to the procedures in Section 2830, Refusal to Comply with Service Delivery Provisions. If the person is unavailable because of temporary nursing home admission, use the time limits and procedures in Section 2822, Service Suspension by Caseworkers.

If a caseworker contacts an applicant or person to schedule or complete a home visit or reassessment and the person states they are unavailable, the caseworker must document the contact and the reason for the delay of the home visit or reassessment. The caseworker should schedule a future date for the home visit or reassessment when the person will be available. If unable to schedule the visit for a future date, the caseworker must contact the person at least weekly until the home visit or reassessment can be completed. This documentation will be considered as an acceptable reason for the delaying a required home visit or reassessment.

2661.1 Delay in Home Visits Due to the Person's Illness

Revision 24-5; Effective Nov. 1, 2024

While required home visits must be completed on a timely basis, due to the increase in transmittable diseases in the general population, there may be circumstances that could place staff at risk for contracting contagious illnesses.

To ensure the health and safety of staff members who could encounter people reporting a contagious illness, caseworkers may delay home visits under the following circumstances.

If a caseworker contacts an applicant or person to schedule a home visit and the person states they have a contagious illness such as influenza, the caseworker must document the contact and the reason for the delay of the home visit, including the stated illness. The caseworker should schedule a future date for the visit when the person thinks they will be better. If unable to schedule the visit for a future date, the caseworker must contact the person at least weekly until the home visit can be made. Each contact must be documented. This documentation will be considered as an acceptable reason for delaying a required home visit if applicable.

2662 Redetermination of Financial Eligibility

Revision 26-1; Effective March 1, 2026

Program Standard: The caseworker must redetermine financial eligibility within 24 months of the previous determination of financial eligibility.

The financial reassessment must be completed by the last day of the 24th calendar month from the previous financial redetermination. To redetermine financial eligibility for income-eligible people, use the policies and procedures in 3000, Eligibility for Services. The caseworker must:

• compare income and resources reported this year with the information previously reported;
• discuss with the person any discrepancies between the two; and
• verify the existence and amounts of new income or resources if these added assets bring the person within proximity to eligibility limits.

Caseworkers must be diligent to make sure people receiving personal attendant services (PAS) are served by Title XIX PAS when possible. If the financial situation of an ongoing Family Care (FC) person has changed in a way that might make them eligible for Community Attendant Services (CAS), a referral should be made to Medicaid for the Elderly and People with Disabilities (MEPD) at the next financial reassessment.

Example: An FC person was denied CAS eligibility at the time of application because of resources that exceeded the $2,000 eligibility limit. However, the person now reports a total of $1,200 in resources and other CAS eligibility, such as a need for a personal care task, are met. At the financial reassessment, a referral to MEPD must be made.

Note: If the person is referred to MEPD for CAS and is denied because of income or resources, the caseworker must review the reason for denial and make sure the person continues to meet financial eligibility requirements for Title XX. If the countable income or resources are over the Title XX limits, any active Title XX services must be denied. Refer to 3200, Resource Eligibility Criteria and 3300, Income Eligibility.

2662.1 Financial Reassessments for Community Attendant Services (CAS)

Revision 21-3; Effective September 1, 2021

MEPD staff must redetermine financial eligibility for CAS annually.

Renewal packets are mailed 60-90 days prior to the annual renewal date. Complete and return Form H1200, Application for Assistance – Your Texas Benefits, along with any required verification documents, within 30 days. If Form H1200 and the required verification are not received by the due date, benefits will be denied.

During regular monitoring visits, remind CAS recipients of the importance of completing and returning the renewal form within the 30-day timeframe so they can continue to receive services. Ensure recipients are aware they can complete an annual renewal online through YourTexasBenefits.com  or over the phone by calling 211.

Some CAS recipients may receive Form H1200-SR, Streamlined Redetermination for Medicaid for the Elderly and People with Disabilities, instead of Form H1200. The cover letter for Form H1200-SR will advise the recipient that no action is needed if there are no changes to the reported information and the renewal form does not need to be returned.

Recipients who are receiving CAS and SNAP or TANF benefits will also receive Form H1010, Texas Works Application for Assistance - Your Texas Benefits. Remind CAS recipients that, in addition to completing Form H1200 to renew CAS benefits, Form H1010 must be completed and returned to continue to receive SNAP or TANF benefits.

If verification of ongoing functional eligibility is requested by MEPD at the annual redetermination, send a copy of the Service Authorization System Online (SASO) Service Authorization screenshot to show the recipient remains active on CAS. Use Form H1746-A, MEPD Referral Cover Sheet, to fax the information to the Document Processing Center (DPC).

Related Policy

Guidelines for Completing Form H1746-A. MEPD Referral Cover Sheet, Appendix V

2663 Reassessment of Functional Need

Revision 24-5; Effective Nov.1, 2024

Program Standard: The caseworker reassesses the person's functional needs within 12 months of the previous assessment. The functional assessment must be completed by the last day of the 12th calendar month from the previous functional assessment.

To reassess functional needs, use the policies and procedures in Section 2430, Functional Assessment, and in the instructions for Form 2060, Needs Assessment Questionnaire and Task/Hour Guide.

• For services requiring a functional needs Form 2060 score for eligibility, the caseworker must complete or update the score in Part A of Form 2060 at each annual reassessment.
• For people who receive Day Activity and Health Services (DAHS) or Consumer Managed Personal Attendant Services (CMPAS) as the only service, a Form 2060 score is not required.
• For Family Care (FC), Community Attendant Services (CAS), and Primary Home Care (PHC), the caseworker must review Part B and Part C of Form 2060 at least annually during the interview with the person.

2663.1 Annual Home Visit Required for People Receiving PAS

Revision 24-5; Effective Nov. 1, 2024

Program Standard: A home visit must be conducted with all people receiving Community Attendant Services (CAS) for all annual reassessments and 90- day monitoring contacts. A home visit must be conducted with all people receiving Primary Home Care (PHC) and Family Care (FC) at least once every 24 months at the same time the financial redetermination is conducted.

During the home visit, the caseworker provides oversight of the person's health and safety. The caseworker must evaluate the person's ability to cope with the activities of everyday living in the home environment and identify when changes to the service plan or the addition of other services provided by the Texas Health and Human Services Commission (HHSC) may be of benefit.

For CAS, it is recommended the caseworker complete the annual functional reassessment during the last 90-day monitor for the year before the annual being due. If the annual functional reassessment is not completed during the last 90-day monitoring visit prior to the annual being due, then an additional home visit is required to complete the reassessment. An exception to having to make a home visit is when Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, has been completed within the last 60 days due to an interim change, the caseworker may conduct the annual reassessment by telephone.

For all CCSE services, if a person requests a change at the annual reassessment, the change must be processed within five business days or by the annual reassessment due date, whichever is earlier.

For CAS, Form 2101, Authorization for Community Care Services, will continue to be sent within five business days of the home visit due to the regional nurse approval requirements for the program.

All annual reassessments must be recorded on Form 2314, Satisfaction and Service Monitoring, and in the Service Authorization System Online Wizards (SASOW). It must include the person as the primary contact and the location as a home visit.

2663.2 Determining When a Home Visit is Necessary for Other Services

Revision 24-5; Effective Nov. 1, 2024

For services other than Community Attendant Services, determine if the reassessment should be done in a face-to-face home visit or by phone interview based on the service received and the person's circumstances. Review Section 4000, Specific CCSE Services, for home visit requirements for each specific service.

Individual circumstances that may include the need for a face-to-face reassessment include but are not limited to:

• a service other than Emergency Response Services or Home-Delivered Meals is being added to the service plan;
• people with no phone or who cannot communicate by phone because of cognitive or physical impairments or lack a knowledgeable source to contact;
• Community Care Services Eligibility (CCSE) recipients who are receiving services from Adult Protective Services (APS) or have a history of self-neglect;
• people who have experienced multiple changes in a short time, such as significant changes in health, living arrangements, or caregiver arrangements, and the caseworker is unable to get an accurate assessment that reflects all the changes by phone;
• case transfers to caseworkers or newly hired caseworkers unless the losing and gaining caseworkers discuss and agree on the person's condition;
• people with weak, unreliable, or no caregiver support systems;
• people who have a history of refusal to comply with service provisions;
• people whose health and safety are at risk; or
• people who choose to live in a home with dilapidated, unsanitary, or hazardous living conditions.

Caseworker circumstances may warrant that a home visit be made, such as caseworker trainees assigned to a caseload.

2664 Redetermination of Unmet Need

Revision 24-5; Effective Nov. 1, 2024

The unmet need policy applies to ongoing cases and to applications. At each reassessment, the caseworker must evaluate if the Community Care Services Eligibility (CCSE) services already being purchased are meeting needs that would go unmet unless services were purchased. During the annual functional assessment or for each request for a change in service plan or hours, review each task on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide.

In the Service Arrangement column, determine if needs are being met through other sources or if the person continues to have a need for the task to be purchased. If there are no tasks to be purchased, the person no longer has an unmet need and is no longer eligible. If unmet need exists, continue with the development of an appropriate service plan.

In situations where the person's caregiver also serves as the paid attendant, carefully review the tasks marked C on the Service Arrangement Column on the previous Form 2060. These are the tasks that the caregiver agreed to perform voluntarily at the last assessment. These tasks may not be purchased. If the caregiver states that they are no longer able or willing to provide help with the tasks, then advise the caregiver that the provider will be notified to hire a new paid attendant for those tasks. Document any changes in caregivers or caregiver tasks on Form 2060 and Form 2059-W, Summary of Individual's Need for Service Worksheet. The information on Form 2059-W is entered in the Service Authorization System Online Wizards (SASOW) for Form 2059, Summary of Client's Need for Service.

In reassessment decisions, the policy about duplicate services must be applied.

2670 Notifications at Reassessment

Revision 25-4; Effective Sept. 1, 2025

The person must meet the CCSE eligibility requirements at the time of recertification of financial eligibility and reassessment of functional needs to continue receiving services.

Program Standard – Use Form 2065-A, Notification of Community Care Services, to notify the person in writing of changes in their service plan, to include:

• addition of service(s);
• increase in hours;
• decrease in copayment; or
• loss of priority status based on the person’s request.

Form 2065-A must be sent within two workdays of the decision if the change involves:

• denial of priority status if the applicant requests it;
• an increase in units;
• a decrease in the copayment;
• addition of a new service; or
• denial of a requested change.

Related Policy

26 Texas Administrative Code Section 271.153

2680 Recertification

Revision 21-4; Effective December 1, 2021

When the reassessment is complete, send the following forms to the provider:

• Form 2101, Authorization for Community Care Services, for all Day Activity and Health Services, Primary Home Care, Home-Delivered Meals, Family Care and Residential Care cases when there is a change in the service plan.
• Form 2101, for all Community Attendant Services (CAS) cases, even if there is not a change in the service plan.
• Form 2065-A, Notification of Community Care Services, for all cases when there is a change in the service plan. It is not necessary to send notification if the only change is a transfer from one provider to another.

For Adult Foster Care (AFC), send the following:

• Form 2065-A, for all cases when there is a change in the service plan. It is not necessary to send notification if the only change is a transfer from one provider to another.
• Form 2101, for all cases even if there is not a change.
• Form 2327, Individual/Member and Provider Agreement, update as needed.
• Form 2330, Assessment and Service Plan Approval for Adult Foster Care, even if there is not a change.
• Attachment 2307-F, AFC Rights and Responsibilities, only if the recipient has moved to another home.

Related Policy

Content of Referral Packets, Appendix XIII
Effective Dates, 2811

2710 Monitoring Visits and Contacts

Revision 24-5; Effective Nov. 1, 2024

Program Standard: The caseworker must monitor the person's situation, the service(s) the person receives, and the adequacy of the service plan per the requirements of the specific service they receive.

Monitoring the service plan includes:

• ensuring the person is authorized for the correct Community Care Services Eligibility service or program;
• checking for the appropriate priority level; and
• ensuring that the authorized hours or units of service meet the person's needs.

2710.1 Monitoring Initiation of Services

Revision 24-3; Effective July 1, 2024

In most situations, the three-day and 30-day initiation of service monitoring visits are not required for Community Care Services Eligibility (CCSE) cases. Phone or face-to-face monitoring visits to ensure service initiation are required for two groups of people:

• those with priority status, both three-day and 30-day; and
• those using the Consumer Directed Services (CDS) option for service delivery, for 30-day only.

Review 6332.3, Monitoring CDS Service Initiation.

For these two groups, the caseworker must:

• contact the provider if they determine that services have not been initiated;
• determine the reason for the delay;
• determine when services will begin;
• monitor the progress of service initiation; and
• complete a service satisfaction monitoring contact within 30 days of the first monitoring contact.

Caseworkers should be aware of service initiation issues and complete optional three-day or 30-day contacts if it is deemed appropriate based on the:

• person's medical condition to ensure their health and safety;
• dependability of the person's family or friends resource system;
• impact of environmental circumstances such as unsafe or unsanitary conditions that could become a barrier to service delivery; or
• provider's ability to deliver services within the specified timelines.

Although not required, caseworkers should verify service initiation by:

• contacting the person by phone or home visit;
• contacting the provider contracted to deliver services;
• reviewing notifications of service initiations from providers, including Form 2067, Case Information, or Form 2101, Authorization for Community Care Services;
• considering other reliable verbal or written information received that verifies service initiation; or
• providing the person with notice to contact the caseworker if services are not initiated within a designated time frame.

2710.2 Monitoring Ongoing Services

Revision 25-3; Effective June 1, 2025

The minimum requirements for recipient contacts are:

• Monitor services every six months for all recipients, except those receiving Community Attendant Services (CAS). Contact the recipient:
  • by the last day of the sixth month from the first assessment date for the initial six-month monitor; and
  • by the last day of the sixth month from the previous monitoring contact for ongoing six-month monitors.
• Make a face-to-face visit within six months of the last monitoring contact date for a priority recipient other than CAS. Example: If the previous monitoring contact was made on March 15, the next contact is due on or before Sept.14.
  
  Note:  Other possible circumstances may require a home visit.
   
• For CAS recipients, the required 90-day monitoring visit must be completed with a face-to-face home visit. The 90-day monitoring visit meets the requirement of the six-month monitor.
• For Adult Foster Care recipients, after the first three monthly monitoring contacts, regular six-month monitors must be completed. The first six-month contact is required three months after the 90-day contact.

More contacts or home visits are required if recipient circumstances warrant. Some recipients may need more monitoring, or problems may arise that require more contact. Recipients with weak or informal support systems may need to be seen more frequently. Home visits may be necessary to ensure the recipient’s safety and well-being are not compromised.

Develop a monitoring plan that considers:

• the recipient’s functional needs;
• the capabilities of family or friends’ resource and support systems; and
• the impact of the recipient’s environmental circumstances.

If a home visit is required, inform recipients in advance by phone or in writing. Use Form 2068, Application, Redetermination, or Monitoring for Community Care Services, unless there is an indication of abuse, neglect, exploitation (ANE) or fraud.

Related Policy

Determining When a Home Visit is Necessary for Other Services, 2663.2
Monitoring Community Attendant Services People, 2711
Adult Foster Care, 4100

2710.3 Service Plan Changes at the Monitoring Contact

Revision 24-5; Effective Nov.1, 2024

Reduce hours or terminate services at annual reassessment or any other time the person:

• requests a reduction or termination;
• gains a resource resulting in fewer unmet needs and the need to reduce service hours; or
• is performing all or some activities of daily living due to long-term improvement in functional condition.

The caseworker uses their judgment to determine if the person's long-term improvement is expected to last through the current authorization period or beyond before reducing or terminating services. Review 2721.6, Long-term Versus Short-term Changes in the Person's Condition, for more details to make that determination.

The person and provider may agree to change the number of personal attendant service (PAS) hours provided based on the person's needs without prior approval from the caseworker. The amount of service provided should be enough to meet the person's needs depending on the loss or gain in the person's functional ability to perform activities of daily living.

Caseworker approval or denial is required for all requests to increase PAS service hours previously authorized or to add or delete priority status.

2710.4 Monitoring Documentation Requirements

Revision 26-2; Effective March 1, 2026

The primary purpose of each monitoring contact, be it a home visit or a phone call, is to determine the adequacy of the current service plan and actual service delivery.

Form 2314, Satisfaction and Service Monitoring, must be used for all required monitoring contacts, including three-day, 30-day, 60-day, 90-day, six-month and annual. Assess the quality of services during each monitoring visit. Also assess if the services continue to meet the needs of the recipient by determining that:

• services are delivered per the service plan and as agreed to by the recipient and the provider agency;
• the attendant comes and leaves as negotiated by the recipient, attendant and provider agency;
• the recipient is satisfied with each of the services being delivered; or
• there is a need to change the priority status, increase hours or change other services.

Ask enough questions during each contact to make sure the recipient’s current responses, together with the written case record, address each of the criteria listed above. Review Appendix XVI, Monitoring Questions, for examples of specific questions that may be appropriate.

At every contact, document each of the following:

• Eligibility — Does the recipient continue to meet all eligibility requirements for the authorized services?
• Condition or Status — Has any change in the recipient's condition or situation affected service delivery or adequacy of the service plan, such as priority status or the need for more hours or other services?
• Quality of Services — Have services been delivered per the service plan? Does the attendant perform the required tasks and arrive and leave as scheduled? Is the recipient satisfied with the services that have been delivered?
• Adequacy of Service Plan — Does the service plan need to be changed?

The recipient or the provider agency may request changes in services. Document all requests for changes on Form 2067, Case Information, and include the date the request was received. If the recipient requests a change during the monitoring contact, document the request, the request date and the action to be taken on Form 2314.

Enter all required monitoring contacts in the Service Authorization System Online (SASO) Monitoring Wizard. A copy of the SASO automated Form 2314 must be filed in the case record.

Note: Record other contacts with the recipient outside of the monitoring home visit or phone call, such as other changes or complaints using regional procedures. Do not use Form 2314, Satisfaction and Service Monitoring.

Related Policy

Service Authorization System Online (SASO) Wizards and Use Requirements, 7300

2710.5 Actions Required After Monitoring

Revision 24-5; Effective Nov. 1, 2024

Caseworkers report and discuss with the provider any problems or deficiencies in service provision and strive to resolve them. Review 2736.1, Reporting Service Delivery Issues, for detailed instructions for handling service delivery issues.

2711 Monitoring Community Attendant Services People

Revision 26-1; Effective March 1, 2026

People receiving Community Attendant Services (CAS) are eligible for personal attendant services (PAS) under the provisions of Section 1929(b) of the Social Security Act. The act requires the caseworker to monitor the home and community care by visiting each person’s home or community setting where care is being provided at least once every 90 days.

An HHSC caseworker must meet this requirement by conducting a face-to-face visit with the person receiving CAS in the person’s home or community setting where CAS services are being provided. This face-to-face visit must occur at least once every 90 days. The 90-day visit is to monitor the person’s satisfaction with services.

The Texas Health and Human Services Commission (HHSC) must make every reasonable attempt to complete the CAS monitoring per the Social Security Act. To meet the reasonable attempt requirement, caseworkers must adhere to the following guidelines:

• The 90-day monitoring must be completed at least every 90 days with the person or primary caregiver present in the location where services are delivered.
• All attempts to contact the person must be documented to support the efforts to meet the federal requirement. A 90-day monitoring contact may not be made with an employee of the provider serving the person.
• If the 90-day monitoring visit becomes delinquent, it must still be completed at the earliest possible opportunity. The caseworker must document all attempts to contact the person and the reason for the delay until the monitoring is completed.
• In cases where the person is in a nursing facility, hospital or out of the service area, the 90-day monitor must be conducted within 14 calendar days of learning the person has returned to the home or community setting where services are provided. The caseworker must document the dates and reasons for the person's inaccessibility.

Federal law specifically requires home visits every 90 days, not every three months. This 90-day deadline will usually be one or two days short of three calendar months. Example: If a CAS case is monitored on March 15, the next monitoring visit must be on or before June 13, the 90th day after March 15. Review Appendix XVIII, Time Calculation.

For CAS cases, HHSC staff sets the initial 90-day home visit schedule from the date within 90 days of the initial start of care (SOC), as determined by the regional nurse and documented on Form 2101, Authorization for Community Care Services, in the Service Authorization System Online (SASO). The caseworker is not required to conduct a 90-day monitor home visit before the SOC date determined by the regional nurse. Once the initial SOC has been determined, HHSC staff use the Deadline Calculation Chart in Appendix XVIII to calculate when the next 90-day monitoring visit is due. Staff then set the subsequent 90-day monitors. Caseworkers are recommended to conduct the annual reassessment simultaneously with the 90-day monitor due before the first annual reassessment to align future 90-day monitors due at the annual reassessment.

All 90-day monitors must be recorded on Form 2314, Satisfaction and Service Monitoring, in the SASO Monitoring Wizard. Review 7300, Service Authorization System (SASO) Wizards and Use Requirements, for help completing the SASO monitoring visit.

Inform Medicaid for the Elderly and People with Disabilities (MEPD) of any changes that may affect the eligibility of a CAS person

2712 Six-Month Monitoring Contacts

Revision 24-5; Effective Nov. 1, 2024

When a six-month monitoring contact is required but a home visit is not, the contact may be completed by phone. If the person does not have a phone or cannot communicate by phone, and a caregiver or relative can tell the caseworker about the person's condition, service needs and the adequacy of service delivery, the contact may be with a caregiver or responsible relative. If contact cannot be made by phone with the person, caregiver or responsible relative, a face-to-face visit is required. All attempts to contact the person must be documented.

Before a face-to-face or phone contact is made with someone other than the person, make at least two attempted contacts with the person. Document all attempts to contact the person.

For a priority status person, the six month monitoring contact must be a face-to-face visit within six months of the previous contact. Example: If the previous monitoring contact was made on March 15, the next contact is due on or before Sept. 14.

During each six-month monitoring contact, ask about the:

• current condition and situation of the person; and
• appropriate delivery of services.

Determine if any changes are needed in the service plan. The caseworker may have to make a face-to-face contact if the:

• phone contact shows a significant change and the caseworker cannot adequately assess the situation without a home visit Review Section 2721, Functional Changes;
• contact shows a need to add a service or increase hours Review Section 2663.2, Determining When a Home Visit is Necessary for Other Services; or
• person shows dissatisfaction with services and the caseworker cannot adequately assess the situation without a home visit.

A face-to-face contact is not required if the person requests a decrease in hours unless eligibility could be affected.

2720 Interim Changes

Revision 17-1; Effective March 15, 2017

2721 Service Plan Changes

Revision 24-5; Effective Nov. 1, 2024

Changes to the service plan may be necessitated by changes in the person’s functional abilities or personal circumstances, including:

• hospitalizations;
• severe acute illnesses or accidents, or recoveries from significant illnesses or accidents;
• loss of or changes in caregivers; and
• moves or changes in living arrangements.

2721.1 Person's Responsibility to Report Changes

Revision 24-5 Effective Nov. 1, 2024

Discuss with the person the importance of reporting changes. Explain the consequences of failing to do so. If the person receives Primary Home Care (PHC), Community Attendant Services (CAS), Family Care (FC), or Home-Delivered Meals (HDM), explain the need to notify the provider if the person will not:

• be home when services are scheduled; or
• need services when scheduled, important for people with priority status receiving personal attendant services.

2721.2 Provider Responsibility to Report Changes

Revision 24-5; Effective Nov. 1, 2024

Attendants report to their supervisors any changes in the person's status or environment that threaten the person's health or safety, or that may affect their service plan. The provider’s supervisor reports these changes to the caseworker. Examples of these changes include hospitalizations, episodes of illness, changes in functional abilities, bruises, mental instability that endangers the person or others, onset of incontinence, unusual complaints of pain, unusual behaviors, or unusual changes in food intake.

The attendant also reports changes that may affect social resource systems, family relationships and assistance programs.  Examples include changes or problems in housing, household make-up, loss or change in caregiver arrangements, or loss of benefits. If necessary, refer the person to Adult Protective Services.

If a provider fails to report changes that affect a person's service plan, the problem must be discussed with the provider staff. If the problem continues, document the instances, and discuss them with the Community Care Services Eligibility (CCSE) supervisor, who notifies the contract manager and program manager.

2721.3 Determining if a Home Visit is Necessary

Revision 24-5; Effective Nov. 1, 2024

The caseworker will use their judgment to decide if they have enough information to respond to the reported change without visiting the person. If in doubt, a home visit should be made. Consider the following when making that determination:

• Is the caseworker already very familiar with the person's situation?
• Does the information available about the change and its impact seem clear and appear reliable?
• Is the reported change relatively simple or more complex? Examples: Several changes at once or sudden and severe deterioration.
• Is there disagreement between what others say the person now needs and what the person is saying they need?

Make a home visit and complete a functional reassessment if the person needs or requests a new service, and their current Form 2060, Needs Assessment Questionnaire and Task and Hour Guide score is below the minimum score for that service.

Reduce hours or terminate services at annual reassessment or any time before the annual review when the person:

• requests a reduction or termination;
• gains a resource resulting in fewer unmet needs and the need to reduce service hours; or
• performs all or some activities of daily living due to long-term improvement in functional condition resulting in the need to reduce or terminate services.
   

2721.4 Revising the Service Plan

Revision 25-4; Effective Sept. 1, 2025

Program Standard: The caseworker must revise the service plan within 14 calendar days of learning that the person's status or condition changed or must document why no changes to the service plan are needed. If the caseworker becomes aware of the need for a service plan change because of an annual reassessment, the change must be completed as part of that reassessment.

Contact the person and determine if a new assessment, a revised service plan or a revised monitoring plan is needed based on the person's new condition or situation. Assess the person’s needs and develop or revise the person's service plan, including:

• Form 2060, Needs Assessment Questionnaire, Task and Hour Guide;
• personal attendant services tasks;
• priority level; and
• number of hours or units of service the person is authorized to receive per week.

2721.5 Long-term Versus Short-term Changes in the Person's Condition

Revision 24-5; Effective Nov. 1, 2024

The caseworker uses their judgment to determine if the change in the person's condition is expected to last through the current authorization period or beyond before reducing or terminating services. Do not reduce or terminate services if it is determined the person is experiencing temporary improvement in functional condition.

If it is determined the person's condition has temporarily improved because the person is performing tasks previously done by the attendant, the person and provider may agree to fewer hours per week. Send the provider Form 2067, Case Information, to inform the provider that fewer service hours may be provided if the person agrees to the reduction. In this situation, the caseworker would not update the Service Authorization System Online (SASO) record or send Form 2065-A, Notification of Community Care Services, to the person for a reduction of hours.

If a change in the person's condition impedes their functional ability to perform activities of daily living, it may be necessary to add additional hours or tasks to the service plan. Caseworker approval or denial is required for all requests to increase personal attendant services hours previously authorized or to add or delete priority status. The amount of service provided must be enough to meet the person's needs.

2721.6 Authorizing and Documenting Changes

Revision 25-2; Effective March 31, 2025

Document all requests for changes in services, including the date of the request, whether received from the person or the provider.

Make all necessary changes in the service arrangement column on Form 2060, Needs Assessment Questionnaire and Task or Hour Guide. To authorize changes in priority level or hours, update and submit Form 2101, Authorization for Community Care Services. Send Form 2065-A, Notification of Community Care Services, to the person if the:

• Primary Home Care, Community Attendant Services, or Family Care hours increase or decrease;
• person gains or loses priority status;
• number of home-delivered meals per week changes; or
• authorized units of Day Activity and Health Services change.

Document the outcome of the change request. If it is determined that no revision is needed in the service plan, document the decision, the reason, and send Form 2065-A, Notification of Community Care Services. Also send Form 2067 if the provider or regional nurse requested the change.

2722 Person Moves and Case Transfers

Revision 25-3; Effective June 1, 2025

At times, a person's move requires transferring their case to a new caseworker within the same or a different region.

When a person moves to an area served by a different caseworker within the same region or outside the region, the case remains open, and the existing service plan stays in effect until a new plan is implemented. Make every effort to minimize gaps in coverage for the person. Although the old plan remains in effect until amended, actual services may have to be temporarily suspended. Example: The new area or region does not have space in a Residential Care (RC) or Day Activity and Health Services (DAHS) facility.

Review 2722.1, Procedures if the Losing Caseworker Initiates Action and 2722.2, Procedures if the Gaining Caseworker Initiates Action. Review to determine the required actions for the case transfer.

2722.1 Procedures If the Losing Caseworker Initiates Action

Revision 25-3; Effective June 1, 2025

If the current, losing, caseworker is contacted by the person or the person’s representatives, and the person has not already moved, that caseworker must:

• contact the office in the new location and get the name, address, and phone number of the gaining caseworker to give to the person;
• contact the gaining caseworker by phone and discuss the case;
• provide the gaining caseworker with the individual number so the caseworker can access the Service Authorization System Services (SASO) for current information;
• have the gaining caseworker fax a provider choice list if the current provider does not provide services in the new area.
  • if the same provider will serve the person in the new location, the losing caseworker keeps Form 2101, Authorization for Community Care Services, open and the gaining caseworker makes any needed changes.
  • if moving to another region, the provider number may be different even if the person is staying with the same agency;
• update Form 2101, Authorization for Community Care Services, by entering in the comments section that this is a transfer case and including the negotiated start date and the losing provider's end date;
• mail Form 2101, Form 2059, Summary of Client's Need for Service, and the Provider Referral Supplement to the new provider agency;
• send a copy of Form 2101 to the losing provider;
• update any current Community Care Interest List entries for the person for the new area;
• send Form H1746-A, MEPD Referral Cover Sheet, if applicable, advising of the new address so that the MEPD case can also be updated; and
• advise staff for any other services the person is receiving that the person has moved.
• forward the case record to the gaining caseworker within three business days of confirming the move;

The gaining caseworker must:

• contact the person within 14 calendar days to assess the person's new living arrangements and need for service plan changes and schedule a home visit If needed, review 2663.2, Determining When a Home Visit is Necessary for Other Services, to determine if a home visit is necessary. If the current, losing, caseworker is contacted by the person or the person’s representatives, and the person has already moved, that caseworker must:

Losing worker is contacted and person has already moved:

• The losing caseworker must:
  • contact the office in the new location and get the name, address, and phone number of the gaining caseworker to give to the person;
  • contact the gaining caseworker by phone and discuss the case;
  • provide the gaining caseworker with the individual number so the caseworker can access the Service Authorization System Services (SASO) for current information;
  • forward the case record to the gaining caseworker within three business days of confirming the move.
• The gaining caseworker must:
  • contact the person within 14 calendar days to assess the person's new living arrangements and need for service plan changes;
  • schedule a home visit If needed, review 2663.2, Determining When a Home Visit is Necessary for Other Services, to determine if a home visit is necessary;
  • provide the person a provider choice list if the current provider does not provide services in the new area;
  • update Form 2101, Authorization for Community Care Services, by entering in the comments section that this is a transfer case and including the negotiated start date and the losing provider's end date;
  • mail Form 2101, Form 2059, Summary of Client's Need for Service, and the Provider Referral Supplement to the new provider agency;
  • send a copy of Form 2101 to the losing provider;
  • update any current Community Care Interest List entries for the person for the new area and
  • send Form H1746-A, MEPD Referral Cover Sheet, for all Community Attendant Services (CAS) people to Medicaid for the Elderly and People with Disabilities (MEPD);
    • advise that the person has moved to the service area and needs continued service;
    • provide the old and new addresses.

2722.2 Procedures If the Gaining Caseworker Initiates Action

Revision 25-3; Effective June 1, 2024

If the gaining caseworker is contacted by the person or the person’s representatives, and the person has already moved, that caseworker must:

• contact the losing caseworker by phone and discuss the case;
• ask the losing caseworker to mail the case file;
• forward the case record to the gaining caseworker within three business days;
• get the individual number so the caseworker can access the Service Authorization System Services (SASO) for current information;
• contact the person within 14 calendar days to assess the person's new living arrangements and need for service plan changes;
• schedule a home visit If needed and review 2663.2, Determining When a Home Visit is Necessary for Other Services, to determine if a home visit is necessary;
• provide the person a provider choice list if the current provider does not file provide services in the new area;
• update Form 2101, Authorization for Community Care Services, by entering in the comments section that this is a transfer case and include the negotiated start date and the losing provider's end date;
• mail Form 2101, Form 2059, Summary of Client's Need for Service, and the Provider Referral Supplement to the new provider agency;
• send a copy of Form 2101 and to the losing provider;
• update any current Community Care Interest List entries for the person for the new area and
• send Form H1746-A, MEPD Referral Cover Sheet, for all Community Attendant Services (CAS) people to Medicaid for the Elderly and People with Disabilities (MEPD);
  • advise that the person has moved to the service area and needs continued service;
  • provide the old and new addresses.

The losing caseworker must:

• send case file to gaining caseworker within three business days.

2722.3 Additional Procedures

Revision 17-1; Effective March 15, 2017

The regional nurse does not need to give prior approval unless a reassessment is being conducted at the same time the transfer is being done, and then a copy of Form 2101, Authorization for Community Care Services, needs to be forwarded to the regional nurse with the transfer agency information.

The provider does not have to obtain new physician's orders for prior approval from the regional nurse for a transferring case.

2723 Freedom of Choice

Revision 25-5; Effective Dec. 1, 2025

In areas where there is more than one provider for a specific service, allow the person the freedom to choose and change providers without restriction.

When a person requests to change providers, the caseworker must first determine the person's reason for dissatisfaction and if the person's satisfaction can be met without the provider change. The caseworker completes the following steps within 14 days of the person's request:

• Ask the person or their representative to select a new provider and document the choice.
• Coordinate with both providers the date the current provider will stop providing services and the date the new provider will begin services.
• Update the information on Form 2059, Summary of Client's Need for Service.
• Update Form 2101, Authorization for Community Care Services, by entering:
  • the nine-digit vendor provider number; and
  • a statement in the comments section to document the coordination with both providers and the effective date of the change.
• Send the new provider Form 2110, Form 2059 and Form 2101.
• For non-Community Attendant Services (CAS) cases, send the current losing provider a copy of Form 2101 that reflects the effective date of the transfer.
• On CAS cases where the change is being made in conjunction with an annual reassessment, the regional nurse will:
  • update Form 2101 upon receipt; and
  • send the updated form that shows the effective date of the transfer to the new provider.

The caseworker will send the current, losing provider a copy of the updated form that reflects the effective date of the transfer.

In situations where the person has been suspended due to health and safety reasons and services will continue with a new provider, the HHSC caseworker must determine how much information to share with the new provider about the previous actions. Review 2840.4, Sharing Information with New Providers Regarding Health and Safety Issues.

2724 Medicaid Coverage for People Denied SSI

Revision 24-5; Effective Nov.1, 2024

In most instances:

• receipt of Supplemental Security Income (SSI) entitles a person to Medicaid; and
• loss of SSI eligibility also means loss of Medicaid benefits.

However, there are several exceptions to this, particularly when someone loses SSI eligibility because of income from Social Security benefits. If a CCSE person receives both SSI and Social Security benefits and the SSI is denied because of income associated with Social Security, encourage the person to apply to Medicaid for the Elderly and People with Disabilities (MEPD)  for an eligibility determination. Send a H1746-A, MEPD Referral Cover Sheet to MEPD if the person is interested.

2725 Certificates of Insurance Coverage

Revision 24-5; Effective Nov. 1, 2024

Public Law 104-191, the Health Insurance Portability and Accountability Act of 1996 (HIPAA), requires that health insurers, including Medicaid, furnish certificates of creditable coverage whenever a person ceases coverage under a plan or policy. The certificate provides evidence that the person had prior creditable health insurance coverage that counts toward reducing or eliminating pre-existing condition exclusions under any subsequent health insurance coverage the person may get.

This legislation will affect people who are Medicaid recipients. Information about certificates of coverage is provided to CCSE applicants and people on Page 2 of Form 2065-A, Notification of Community Care Services.

Texas Medicaid & Healthcare Partnership (TMHP) is the contractor that produces these certificates for denied Medicaid people. If a person has questions about the certificate or needs a replacement certificate, they should write or call TMHP.

2730 Special Procedures for Helping People Enter or Leave a Nursing Facility, Institution or Hospice

Revision 26-2; Effective June 1, 2026

2731 People Entering a Nursing Facility

Revision 24-5; Effective Nov. 1, 2024

Some people living in their own homes may need counseling about the available options for receiving long-term care, including nursing facility placement. Caregivers of people with heavy care needs may experience severe stress or be unable to continue their duty for weeks and months without reprieve. People may be at risk if they remain in their current environments. Assess these situations from the standpoints of both the person's safety and the caregiver's ability to withstand the stress of constant care. Offer them the opportunity to consider nursing facility care.

If a person wants to enter a nursing facility, help them make their plans. If the person is not a Medicaid recipient, refer them to Medicaid for the Elderly and People with Disabilities (MEPD) staff to start the financial application process as soon as possible.

If a person lacks family or a responsible person to help them with all the final activities involved in moving into a nursing facility, help them by involving their friends and other volunteers.

Nursing Facility Care for People Under 22

State Law Chapter 242, Health and Safety Code requires that the Community Resource Coordination Group (CRCG) be notified by the third day after the date a Community Care Services Eligibility child under 22 with a developmental disability is initially placed in an institution.

Call the CRCG State Office at 512-206-4564 to get the name and phone number of the CRCG contact person. A CRCG list is also available online (PDF).

If notice is received of an initial placement of a child in an institution, contact the person making the placement to ensure that family members of the family are aware of:

• service and support that could provide an alternative to placement of the child in the institution; and
• available placement options.

2732 Closing Service Authorizations for Individuals Entering or Leaving a Nursing Facility

Revision 17-1; Effective March 15, 2017

2732.1 People Entering a Nursing Facility

Revision 24-5; Effective Nov. 1, 2024

A batch process closes the service authorization records for Community Care people who have entered a nursing facility. When Form 3618, Resident Transaction Notice, is submitted by the nursing facility, all Service Authorization System Online (SASO) authorization records, except Service Code 20-Emergency Response Services, are closed by an automated batch process that occurs five times a week.

The batch process uses the date in Item 11, date of the above transaction, on Form 3618 as the end date of the service authorization.

Regional Claims Management System (CMS) coordinators must access the reports and notify caseworkers when they have people whose service authorization records are closed by the batch process. Caseworkers must monitor these cases for 30 calendar days until it is determined if the person's nursing facility stay will be long term. If the person will be remaining in the facility, the caseworker closes the remaining Service Code 20 record, if applicable.

2732.2 People Leaving a Nursing Facility

Revision 24-5; Effective Nov. 1, 2024

For people being discharged from a nursing facility who are beginning to receive Community Care services, Provider Claims Services has established a hotline number to call to close the nursing facility authorization. The hotline number is 512-438-2200. Select Option 1.

The caseworker should call the hotline directly to request the nursing facility record in the Service Authorization System Online (SASO) be closed so Community Care services can be authorized. The caseworker must confirm the person has been discharged from the facility and Community Care services are negotiated to begin on or after the date of discharge.

When calling the hotline, the caseworker must identify themself as a Texas Health and Human Services Commission (HHSC) employee and report that the person has discharged from the nursing facility and provide the discharge date. The Provider Claims Services representative will close all Group 1 Service Authorizations and Enrollment in SASO, including the Service Code 60. The caseworker documents the contact. 

2732.3 People Denied a Determination of Medical Necessity

Revision 24-5; Effective Nov. 1, 2024

When a Medicaid nursing facility resident is denied a determination of medical necessity, Texas Medicaid & Healthcare Partnership (TMHP) sends a denial letter to the person and the person's physician. The facility and Medicaid for the Elderly and People with Disabilities (MEPD) are notified by TMHP's weekly status report.

If the person requests CCSE services, respond to this request by following the usual intake procedures, including interviewing, and assessing their needs. If the person is determined eligible to receive CCSE services but prefers to receive services outside the intake unit's geographical area, the intake unit staff refers the case to the appropriate caseworker or region. When CCSE staff receive an out-of-town referral or inquiry, they help with alternate placement activities.

2732.4 Promoting Independence Initiative

Revision 24-5; Effective Nov. 1, 2024

Promoting Independence (PI) Initiative, enacted by House Bill 1867 of the 79th Session of the Texas Legislature, helps ensure a system of services and supports that foster independence and productivity, and provides meaningful opportunities for people that are older and people with disabilities to live in their home communities.

Money Follows the Person (MFP) is available for people requiring waiver services. It allows Medicaid funds that are being used to pay for the person's care in a nursing facility to be transferred to pay for Medicaid waiver services in the community. People identified as using MFP-funded services do not use interest list allocations.

MFP does not apply to Community Care Services Eligibility programs.

Review the appropriate program handbook for the desired waiver program for more information.

2733 People Receiving Services through Local Authorities

Revision 25-2; Effective March 31, 2025

Local Authorities (LAs) specialize in working with people who have intellectual developmental disabilities (IDDs), intellectual disabilities (IDs) or people with mental illness, especially those in crisis situations. Close coordination with LAs is vital to ensure the safety and well-being of the person and others. Contact the local LA agency to determine what procedures to follow to get permission from the person to discuss their case with LA staff.

The liaison caseworkers at the LA community center are responsible for helping people with IDD/ID with the process of admission to or discharge from state supported living centers or intermediate care facilities for people with an intellectual disability or related condition (ICF/IID). Refer to the appropriate liaison worker any persons requesting or requiring entry into these facilities. Liaison caseworkers also have primary case management responsibility for people with IDD/ID who return to the community from state supported living centers. Contact liaison workers for specific information about their responsibilities and about the availability of LA resources for people with IDD/ID.

People discharged from state hospitals are referred to the appropriate LA community center or outreach program for follow-up. LA case management services are available to them if they meet eligibility and priority criteria. Contact the liaison worker for specific eligibility information. These people may also apply personally for CCSE services.

If there is no LA caseworker assigned to the person's case, contact the local LA agency to discuss the person's condition. Refer the person to them for services, assistance or case management, if appropriate. Include the LA caseworker in the development of the person's CCSE service plan and clearly define the caseworker's roles and responsibilities in managing the case. Encourage the LA caseworker to offer support counseling and training to the:

• person;
• the person's caregiver; and
• provider of services.

Keep the LA caseworker informed of changes in:

• the person's environment such as hospitalizations, residence, household composition;
• the person's physical and mental condition;
• medications or lack of medication; and
• the service plan.

Document contacts with LA staff, including any agreements reached.

Refer to Appendix XV, Services Available from Other State Agencies, for a list of the services that may be available through the LA agency.

Note: Refer to 1140, Disclosure of Information, about disclosure of information and national standards created under the Health Insurance Portability and Accountability Act to protect the confidentiality of individually identifiable health information.

2734 Texas Department of Corrections (TDC) People Leaving TDC

Revision 24-5; Effective Nov. 1, 2024

Texas Department of Corrections (TDC) staff are responsible for discharge planning for people who are older or people with disabilities being released from TDC. TDC tries to make a referral at least 30 calendar days before the inmate will be released from prison. TDC is represented in the community by the Board of Pardons and Parole (BPP). BPP supervises the person in the community and provides or arranges for other services they may need. Follow the usual case management procedures to certify the person eligible for services, to refer their case for service, and to monitor or evaluate any services authorized.

2735 People Who Need Hospice Services

Revision 24-5; Effective Nov. 1, 2024

Medicare and Medicaid hospice services are available to terminally ill Medicare and Medicaid eligibles who file an election statement with a particular hospice. Hospice applicants must be certified as terminally ill, with six months or less to live, by a physician. For dually eligible people who elect hospice care, coverage is concurrent with the Medicare and Medicaid programs. Hospice care is also available on a private-pay basis.

Hospice staff contact the caseworker by phone about the start and cancellation dates for hospice care. Hospice staff no longer send a copy of Form 3071, Individual Election/Cancellation/Update, to HHSC staff. People may elect or cancel hospice care at any time.

People electing hospice may be eligible for services through HHSC if there is no duplication in the services delivered. A Medicaid recipient, 21 and older, who elects Medicaid hospice waives their rights to other programs with Medicaid services related to the treatment of a terminal illness. The Medicaid recipient does not waive their rights to services offered by HHSC that are unrelated to the treatment of the terminal illness. People under 21 years of age who elect hospice do not waive rights to Medicaid services related or unrelated to the terminal illness.

HHSC caseworkers must follow up with the person receiving services to determine what hospice will provide and adjust the person’s service plan to ensure no duplication of services. Caseworkers must respond to a notification of hospice election within the time frame of a change request.

The unmet need policy in Section 2433, Determining Unmet Need in the Service Arrangement Column, does apply to hospice people. Coordinate any CCSE service plan with the hospice provider to prevent duplication and assure adequate services to the person. If the hospice provider adequately meets a person's need for help with a particular task, do not authorize purchased services for that task.

If the hospice provider does not meet the need for help, or if the need is only partly met, authorize services on the same basis as those used for any other person.

Caseworkers may receive a request to initiate a CCSE service for a person already receiving that service from a hospice. In this case, it must be determined if the hospice will continue to provide the needed care. Authorize the CCSE service if the hospice service ends on a certain date or if the hospice provider will provide the service only until the CCSE service can begin. Coordinate service initiation and ending dates with the hospice provider to prevent a break in services. When a CCSE person enters a nursing home under hospice, terminate CCSE services effective the date the person entered the facility. If the person receives hospice care at home, making reduction or termination of CCSE services necessary, give the person the usual 12-day advance notice before the effective date of the reduction or termination.

If a person with Medicaid for the Elderly and People with Disabilities (MEPD) eligibility determination (Community Attendant Medicaid Hospice Program Services) enters a nursing facility under Medicaid hospice, the caseworker notifies the MEPD of the Hospice nursing facility entry and closure of the HHSC case by sending Form H1746-A, MEPD Referral Cover Sheet.

In related situations, hospice services should be considered as a resource available to CCSE applicants and recipients. Monitor CCSE people on an ongoing basis to determine if they need or are receiving hospice services.

Note: Refer to Section 1140, Disclosure of Information, about disclosure of information and national standards created under the Health Insurance Portability and Accountability Act to protect the confidentiality of individually identifiable health information.

2736 Complaints, Grievances or Suggestions

Revision 24-5; Effective Nov. 1, 2024

The applicant or person has the right to lodge a complaint, voice a grievance, or recommend changes in policy or service without restraint, interference, coercion, discrimination or reprisal. Staff must:

• acknowledge the complaint, grievance, or recommendation within 14 calendar days of the date the Texas Health and Human Services Commission (HHSC) receives it; and
• resolve it within 60 calendar days of that date.

2736.1 Reporting Service Delivery Issues

Revision 24-5; Effective Nov. 1, 2024

Provider service delivery issues may be reported to the Texas Health and Human Services (HHS) Office of the Ombudsman. These reports may be generated by:

• the person or person's representative;
• Texas Health and Human Services Commission (HHSC) staff, including issues discovered by the caseworker or reports received during monitoring contacts; and
• other people, including the person's family and friends.

Service delivery issues include any dissatisfaction expressed by the person about a service delivery provider. The person may express dissatisfaction about:

• the quality of a service provided, such as care, treatment or services received;
• aspects of interpersonal relationships, such as rudeness; or
• the service provider's failure to:
  • respect the person's rights;
  • follow terms of the contract or applicable rules; or
  • provide services that may or may not have had an adverse effect on the person.

This list is not all-inclusive.

Report complaints of a regulatory nature about nursing facilities, home and community support service agencies, intermediate care facilities, assisted living facilities, day activity and health services, prescribed pediatric extended care centers, and Home and Community-based Services and Texas Home Living providers to Consumer Rights and Services at 800-458-9858 or ciicomplaints@hhs.texas.gov to generate an investigation by HHSC Regulatory Services.

Within five business days of receiving a report or becoming aware of service delivery issues, the caseworker:

• must respond to the person and the provider either by phone or face-to-face contact to discuss the issues;
• must inform the provider of the service delivery issues and discuss resolutions;
• convenes an interdisciplinary team (IDT) meeting if appropriate;
• coordinates with the person and provider to implement actions required to resolve the issues;
• must document the receipt of the report and contacts with the person and the provider in the case record;
• must document any barriers or hindrances by either party that interfere with the resolution of the issues; or
• attempts to resolve the issue must be documented.

If service delivery issues cannot be resolved within 10 business days of the initial receipt of a report or of becoming aware of service delivery issues, the caseworker must:

• report the service delivery issues to the HHS Office of the Ombudsman at 877-787-8999;
• inform the person of their right to call the HHS Office of the Ombudsman to register a complaint about the provider, including a Consumer Directed Services (CDS) agency; and
• inform the person of their right to choose another provider.

The caseworker must make the report to the HHS Office of the Ombudsman within three business days after the 10 business day resolution period ends.

In situations where service delivery issues may compromise the person's health and safety, the caseworker must report within 24 hours of receiving the report or becoming aware of service delivery issues. The caseworker must:

• also contact Adult Protective Services (APS) or Child Protective Services (CPS) within 24 hours if there is an immediate or imminent threat to the health and safety of the person; and
• continue to work with the person and provider to resolve the issues within the 10 business day time frame.

The caseworker must identify the specific service the provider is delivering when calling to report a complaint.  Example: the caseworker identifies the provider as a Primary Home Care (PHC) provider when making a referral that involves PHC service delivery issues. The caseworker must provide specific information related to the service delivery issues, including actions taken to resolve the issues and why the actions did not resolve them.

2740 Fraud, Waste and Abuse Detection and Documentation

Revision 25-5; Effective Dec. 1, 2025

2741 Provider Fraud, Waste and Abuse

Revision 25-5; Effective Dec. 1, 2025

HHSC endorses the concept that people who provide services are essentially honest and are entitled to the same protection under the law as all other people. However, when there is an indication of potential fraud, waste and abuse (FWA), the allegations must be investigated.

Some examples of provider FWA include:

• billing for services that were not provided;
• providing services that are not medically necessary;
• filing false claims;
• continuing inappropriate billing after provider education visits;
• billing for services provided by inappropriate persons;
• practicing without a proper license or obtaining a license under false pretenses;
• using improper billing practices; and
• violating the contract or provider agreement.

Note: This list is not all-inclusive.

2742 Responding to Allegations of Provider FWA

Revision 25-5; Effective Dec. 1, 2025

When an allegation of provider FWA is received, staff should follow these procedures:

• During the first contact, staff who receive the complaint should obtain facts that relate to the specific case in as much detail as possible. This includes:
  • who engaged or participated in the alleged conduct, including the name of the associated business entity and the names of any provider staff involved,
  • what the suspected violation was,
  • when the conduct occurred dates or time periods,
  • where the conduct occurred, including the address of the associated business entity,
  • how the conduct was performed, and
  • the names of witnesses and their contact information.
• Staff should try to obtain the complainant's name, address, phone number and email address where the complainant can be reached during the day.
• Staff must not make any agreements or commitments to anyone regarding the investigation or any possible adverse action.

2743 Personal FWA

Revision 25-5; Effective Dec. 1, 2025

People who receive HHSC services are perceived as honest and entitled to the same protection under the law as all other people. However, when there is an indication of potential FWA, the allegations must be investigated.

Some examples of personal FWA include:

• knowingly providing false information about an applicant's financial, medical or functional status to be determined eligible for assistance;
• withholding or concealing information about the applicant's financial, medical or functional status, which may cause the applicant to be ineligible for services;

Note: This list is not all-inclusive.

2744 Responding to Allegations of Personal FWA

Revision 25-5; Effective Dec. 1, 2025

When potential personal FWA is discovered, staff should follow these procedures:

• Record all pertinent facts that relate to the specific case in as much detail as possible. This includes:
  • who engaged or participated in the alleged conduct, including the name of the associated business entity and the names of any provider staff involved;
  • what the suspected violation was;
  • when the conduct occurred dates and time periods;
  • where the conduct occurred, including th address of the associated business entity;
  • how the conduct was performed; and
  • the names of witnesses and their contact information.
• Staff should try to obtain the complainant’s name, address, phone number and email address where the complainant can be reached during the day.
• Staff must not make any agreements or commitments to anyone regarding the investigation or any possible adverse action.

2745 Reporting Suspected Personal or Provider FWA

Revision 25-5; Effective Dec. 1, 2025

When the CCSE caseworker suspects FWA was committed by the provider or person receiving services, the caseworker must report the suspected FWA to the HHS Office of Inspector General (OIG). The following are established procedures for reporting suspected provider or personal FWA to the OIG. Before submitting a referral, consult the unit supervisor for guidance to determine the appropriateness of the referral and the information being provided. An FWA referral to OIG is initiated even if the potential FWA does not affect Title XIX funds.

If it is determined a referral will be submitted, the caseworker can submit the referral to OIG at ReportTexasFraud.com 24/7 with an option to upload related documents. The referral can also be submitted by calling 800-436-6184 or by mail to:

HHS Office of Inspector General
Mail Code 1361
P.O. Box 85200
Austin, TX 78708-5200

Provide as much information as possible. Helpful information includes:

• the name of the person providing the information.
• additional contact person, if available.
• name of the person reporting the FWA if different from the person providing the information.
• law enforcement information, if available, indicate if law enforcement notified.
• witness information, if available.
• name of the person or facility being reported.
• detailed information about the FWA concern, including:
  • provider identification including the name, provider type and specialty, business address, residence address and provider numbers;
  • identification of the alleged illegal act including specific data about potential witnesses, addresses, work and home phone numbers;
  • names, mail codes and phone numbers of all staff who can provide information;
  • identification of policy, regulation or procedural violations;
  • numerical reference and manual title, the department rule or policy clearance letter;
  • the specific chapter, subchapter, page number and effective date of the manual or publication source;
  • who or what initiated the allegation; and
  • other pertinent documentation about the case.
• date of birth and Social Security number of the person you suspect is committing FWA.
• the phone number and address of the person you suspect.
• a description of the allegation.
• any other information the caseworker thinks might be helpful to an investigator.

After submitting the referral, the caseworker will receive a tracking number. Document the tracking number. You will need it if you have more information to add later.

HHSC is responsible for making sure all pertinent information is obtained and may request more information later. Providing requested material to HHSC does not constitute a confidentiality violation. Staff in that division conduct an analysis and collect data to create a complete picture of the alleged incident.

After referring the case to HHSC, no other action is necessary. Continue to maintain the case as usual. HHSC staff should preserve a professional working relationship with the provider, person or authorized representative while the FWA referral is being investigated. However, for the duration of the investigation, staff must not discuss the alleged violation with unauthorized personnel. This prevents the possibility of interference with the investigation.

2750 Reporting Suspected FWA in the Consumer Directed Services Option

Revision 25-5; Effective Dec. 1, 2025

The following are established procedures for reporting suspected FWA in the CDS option to the HHS OIG. These apply when a suspected FWA is committed by the person receiving services, the CDS employer or the CDS employee. They do not apply to provider FWA. Before submitting a referral, consult with the unit supervisor for guidance to determine the appropriateness of the referral and the information being provided.

When the CCSE caseworker suspects FWA was committed by the person receiving services, the CDS employer or the CDS employee, or is made aware of suspected FWA from an entity other than the Financial Management Services Agency (FMSA), the caseworker must report the suspected FWA to the OIG. The caseworker can submit the referral to OIG at ReportTexasFraud.com 24/7 with an option to upload related documents. The referral can also be submitted by calling 800-436-6184. The caseworker must inform the OIG the person is using the CDS option.

Provide as much information as possible. Helpful information includes:

• date of birth and Social Security number of the person you suspect is committing FWA.
• the phone number and address of the person you suspect.
• a description of the allegation.
• any other information the caseworker thinks might be helpful to an investigator.

After submitting the referral, the caseworker will receive a tracking number. Document the tracking number, you will need it if you have more information to add later.

Once the caseworker submits the FWA referral to the OIG, the caseworker uses Form 2067, Case Information to inform the FMSA about the suspected FWA. The caseworker must also send a secure email to CDS Operations staff at the state office containing the following information for tracking purposes:

• name of the FMSA;
• name of the person(s) suspected of committing FWA;
• as much identifying information as possible, such as Social Security number, Medicaid number, date of birth, address and phone number;
• brief summary of the FWA allegation, including dates and estimated cost because of the violation;
• date the FWA allegation was reported to the OIG and the OIG referral tracking number;
• program or service impacted; and
• contact information for the CCSE caseworker who submitted the referral and the HHSC office where the caseworker is located.

When an FMSA suspects FWA was committed by the person receiving services, the CDS employer or the CDS employee, the FMSA makes a referral to the OIG. The FMSA informs HHSC CDS Operations staff at state office that the FMSA submitted an FWA referral to the OIG for tracking purposes.

The FMSA also uses Form 2067 to inform the CCSE caseworker that an FWA referral was submitted to the OIG. The caseworker must file Form 2067 received from the FMSA in the person’s case file. No further action is needed by the caseworker about the FWA referral once the FMSA notifies CCSE the referral was made to the OIG.

2751 Reserved for Future Use

Revision 25-5; Effective Dec. 1, 2025

2752 Expedited Referrals

Revision 25-5; Effective Dec. 1, 2025

If staff have reason to believe that the conduct of the suspected provider, person or authorized representative is serious enough to require immediate action, it may be appropriate to expedite the referral. As with routine referrals, the unit supervisor must first be consulted. An expedited referral should be made when a delay would probably result in:

• the loss, destruction or altering of valuable evidence;
• harm to a person;
• significant monetary loss to HHSC that would probably not be recoverable; or
• delay of an investigation or criminal prosecution of the alleged offense.

In these situations, the case is immediately referred to HHSC OIG at ReportTexasFraud.com 24/7 with an option to upload related documents or call 800-436-6184.

2753 Reserved for Future Use

Revision 25-5; Effective Dec. 1, 2025

2810 Individual Notification Procedures

Revision 24-5; Effective Nov. 1, 2024

Program Standard – Within two business days after the decision, notify the person in writing. Use the SASO generated Form 2065-A, Notification of Community Care Services, of all eligibility and ineligibility decisions or any changes in the person’s service plan. Review Form 2065-A, Instructions.  

When notifying the applicant of eligibility, specify on Form 2065-A:

• the Community Care Services Eligibility (CCSE) services that the applicant is eligible or ineligible for; and
• if determined eligible:
  • the number of hours of services the applicant is authorized to receive or the number of days or half days the applicant is authorized to attend a Day Activity and Health Services (DAHS) facility;
  • if applicable, that the Family Care, Primary Home Care or Community Attendant Services applicant is eligible for priority status;
  • the initial and ongoing room and board payments for Residential Care and Adult Foster Care; and
  • the initial and ongoing copayments the Residential Care the person will pay to the facility.

An applicant or person certified for one CCSE service but determined ineligible for another must be notified in writing of both decisions. An applicant or person certified for personal attendant services or home-delivered meals must also be notified in writing of the hours per week or meals per week they are eligible to receive. If certified for DAHS, the applicant or person must be notified in writing of the number of days per week the DAHS authorization covers. The written notice for all services must contain the caseworker's name, phone number and appeal procedures.

For ongoing people, on Form 2065-A, record the:

• action taken and the effective date; and
• name of the CCSE service(s) that the action is based.

If the notification is an adverse action, the notice must also state the:

• reason for the adverse action; and
• CCSE Handbook reference that the adverse action is based on.

Review the Form 2065-A Attachment for handbook and rule references.

CCSE staff may notify a person verbally of continued eligibility if the person continues to qualify for the same service(s) and the number of hours or units of service remains the same. 

2811 Effective Dates

Revision 25-4; Effective Sept. 1, 2025

The Texas Health and Human Services Commission (HHSC) caseworker uses Form 2065-A, Notification of Community Care Services to notify the applicant or recipient of any adverse action that denies, suspends, reduces or terminates services. In general, the HHSC caseworker sends the notice of adverse action to the person 12 calendar days before the effective date of the action. In situations where services were suspended because of threats to health and safety, the HHSC caseworker sends the written notice of adverse action without advance notice if the crisis cannot be resolved.

An applicant or recipient has the right to appeal any decision that denies, reduces or terminates their services and request a fair hearing per Title I, Texas Administrative Code (TAC) Chapter 357.

For an adverse action, if the day after the effective date is a Saturday, Sunday or legal holiday, the adverse action period is extended to include the next day that is not a Saturday, Sunday or legal holiday. Skeleton crew days are not legal holidays. Legal holidays are days when the agency is closed. Review Appendix IX, Notification Effective Date of Decision, Appendix XVIII, Time Calculation and 2652, Changing the Service Schedule Between Reassessments for information about calculating effective dates of reduction or termination of services.

The date at the top of Form 2065-A is the date the HHSC caseworker completes the form. Since offices have different mail pickup times, staff are not required to consider the mail date when completing the form. Staff must make sure applicants and recipients are notified within the required time frames.

Services are reduced or terminated at annual reassessment or any other time the caseworker becomes aware before the annual review when the person:

• requests a reduction or termination;
• gains a resource that results in fewer unmet needs and the need to reduce service hours; or
• is performing all or some activities of daily living because of long-term improvement in functional condition that results in the need to reduce or terminate services.

People may request an appeal of any decision that denies, reduces or terminates their benefits. The effective date of the action depends on the situation, as shown in the following table:

2812 Changes in the Person's Need for Services

Revision 25-2 Effective March 31, 2025

Before reducing or terminating services caseworkers determine if the person's long-term improvement is expected to last through the current authorization period or beyond.

If it is determined that the person's condition has temporarily improved because the person is performing tasks previously done by the attendant, the person and provider may agree to fewer hours per week.
Do not reduce or terminate services if it is determined the person is experiencing temporary improvement in their functional condition. If the person feels they temporarily need fewer hours, send the provider Form 2067, Case Information, informing the provider that fewer service hours may be provided if the person agrees to the reduction. If the person is experiencing temporary functional improvement, the caseworker would not change the task and hour guide or authorization or send Form 2065-A, Notification of Community Care Services, to the person for reduction of hours.

The person and provider may agree to change the delivery schedule for personal attendant services (PAS) hours based on the person's needs without prior approval from the caseworker.

Caseworker approval or denial is required for all requests to increase PAS hours previously authorized or to add or delete priority status. In these situations, terminate or reduce services 12 calendar days after the Form 2065-A completion date. Review 2652, Changing the Service Schedule Between Reassessments, 2811, Effective Dates, Appendix XVIII, Time Calculation and 2721.6, Authorizing and Documenting Changes.

2813 Situations in Which the 12-Day Adverse Action Period May Be Reduced

Revision 24-5; Effective Nov. 1, 2024

There may be situations when a person wants to waive or shorten the 12- calendar day notice period before services are reduced or terminated. Some examples of these situations include:

• A Family Care person is being removed from an interest list for Title XX Day Activity and Health Services (DAHS) and wants to withdraw or have services reduced in less than 12 calendar days to attend DAHS immediately; or
• Community Care Services Eligibility People who prefer to receive 1915(c) waiver services may also wish to have the change take place in less than 12 calendar days.

If the person indicates a desire to waive or reduce the 12 calendar day advance notice, be very cautious and remember that a person may change their mind. In most instances, the provider can be verbally notified to stop service and still maintain the formal effective date of 12 calendar days in the future.

If the person still wants to waive or shorten the 12 calendar day advance notice, complete Form 2065-A, Notification of Community Care Services, with the effective date being the date the person wants services to end or be reduced. Explain in the comments section that the person is voluntarily waiving or reducing their right to the 12-calendar day advance notice. The person must:

• sign this statement; and
• be given the original and one copy of the notice.

2814 Transfers Between Primary Home Care, Community Attendant Services and Family Care

Revision 25-3; Effective June1, 2025

Send Form 2065-A, Notification of Community Care Services, when a person is transferred between any of the three programs listed below:

• Primary Home Care (PHC);
• Community Attendant Services (CAS); or
• Family Care (FC).

Do not send another form to terminate the previous service. Specify on the form:

• name and amount of the previous service;
• name and amount of the new service;
• the effective date of the transfer; and
• reason for the transfer.

Show in the comments section that the person should not notice any difference in the amount or type of services received because of this transfer.

Example: The service you were receiving, Primary Home Care, 16 hours per week, will change to Family Care, 16 hours per week, effective June 1, 2024.

Comments: Primary Home Care will terminate because you lost financial eligibility for that program. You should not notice any difference in the amount or type of services you will receive because of this transfer.

Example: The service you were receiving, Family Care, 10 hours per week, will change to Community Attendant Services, 10 hours per week, effective March 3, 2025.

Comments: Family Care will terminate because you have been determined financially eligible for Community Attendant Services.  You should not notice any difference in the amount or type of services you will receive because of this transfer.

Although Form 2065-A must be sent when a person transfers between PHC, CAS, and FC, the effective date is either the negotiated date or the date following the Medicaid end date.

Review 4600, Primary Home Care and Community Attendant Services, for more transfer procedures.

Related Policy

Appendix IX, Notification/Effective Date of Decision
Appendix XVIII, Time Calculation

2820 Service Suspensions

Revision 24-5; Effective Nov. 1, 2024

Services may be suspended by the provider or by the caseworker.

2821 Service Suspension by Providers

Revision 24-5; Effective Nov. 1, 2024

Providers may suspend services to people. Review 4000, Specific CCSE Services for information about suspensions of each specific service.

On the day of suspension or by the first HHSC business day following suspension, the provider must contact the caseworker to explain the reason for suspending services.

If a person meets the criteria for Adult Protective Services (APS), refer them. Refer other people to other appropriate service resources as needed.

The caseworker documents the incident that caused the suspension and the date of the incident. The results of any related interdisciplinary team (IDT) meetings must be included in the documentation. After evaluating suspensions to determine if services should be terminated and the case closed, the caseworker takes the appropriate action. In some situations, the problems that caused the suspension can be resolved. If they are resolved:

• send Form 2067, Case Information, to the provider documenting the problem resolution; and
• reach an agreement with the provider about the date on which services will be reinstated.

2822 Service Suspension by Caseworkers

Revision 25-4; Effective Sept. 1, 2025

A person is not eligible for CCSE services when:

1. they die;
2. they are admitted to an institution;
3. their physician requests service termination for Medicaid services only;
4. they request service termination or repeatedly refuse to accept help, except in an involuntary protective services case; or
5. they refuse to comply with their service plan.

Related Policy

26 Texas Administrative Code Section 271.155(c)

2822.1 Hospital and Nursing Facility Stays

Revision 24-5; Effective Nov. 1, 2024

Suspend services when available information confirms that a nursing home or hospital stay will be longer than 30 calendar days. Use Form 2067, Case Information, to notify the provider to suspend services effective the date of nursing home or hospital entry. Sending updates to the provider is optional.

Continue to monitor the situation. If the person has not returned home by the 30th calendar day, contact the person or authorized representative (AR) to see if a discharge date is planned. If the person has a planned discharge date within the next 30 calendar days, leave the case open and monitor on the planned discharge date.

Terminate services, using the date of admission as the effective date of termination, if information shows that the nursing facility or hospital stay will be more than 30 calendar days.  Exception: The effective date of termination for Residential Care should be the 30th day after admission to the nursing facility or 60 days after admission to a hospital.

Consult with the person, family, and others associated with the person to determine the length of stay. Be cautious about terminating Title XX services, especially if the region has an interest list for those services.

Emergency Response Services (ERS) may remain open until the decision is made to terminate all services because the nursing facility stay has become permanent. Review 4300, Emergency Response Services, for suspension of ERS by the ERS provider.

The following situations should always be considered short-term, and services should be suspended for up to 30 calendar days rather than terminated:

• admission to a swing bed facility; and
• admission to a hospital for mental illness treatment.

Services may be suspended indefinitely if the person is admitted to a rehabilitation hospital or to a rehabilitation floor or wing of a medical hospital.

2829 Unable to Locate

Revision 25-2; Effective March 31, 2025

The person must be available for reassessments, monitoring, and service delivery to stay eligible for Community Care Services Eligibility (CCSE) services. If a caseworker cannot locate the person, they must contact the provider to determine if services are being delivered.  If no services are being delivered and the provider agency has no information about where the person is the caseworker must try to contact family members, authorized representatives or other people who may have information about the person. 

If all attempts to find the person are unsuccessful, services may be terminated by sending Form 2065-A, Notification of Community Care Services, allowing 12 days adverse action for the person to contact the caseworker.  Refer to 2811, Effective Dates and Appendix IX, Notification Effective Date of Decision.

2830 Refusal to Comply with Service Delivery Provisions

Revision 25-4; Effective Sept. 1, 2025

Examples of refusal to comply with the service delivery provisions include, but are not limited to:

• The person is often away from their residence when a service is scheduled. They repeatedly fail to notify the provider that they will be gone, even though they have been counseled about this problem and its implications.
• The person or someone in the person’s home will not permit the provider to perform one or more of the tasks in the service plan regularly. The person receives personal attendant services and refuses to allow the provider to perform the authorized tasks.
• Despite several provider efforts to find and place an acceptable attendant in the home, the person refuses to accept services because they are dissatisfied with a particular attendant.
• The person or someone in the person’s home regularly behaves in such an offensive way to staff that staff refuses to serve them. The person knowingly and passively condones the abusive behavior, and the staff cannot provide services. Examples include sexual harassment, sexual misconduct and racial discrimination.

If the provider notifies the Texas Health and Human Services Commission about a service delivery compliance problem, contact the person or the responsible party. Attempt to resolve the issue in a way that satisfies the person and the parties involved. An interdisciplinary team (IDT) meeting may be conducted at the person’s home to try to resolve the situation.

Related Policy

26 Texas Administrative Code Section 271.155 
 

2830.1 People Who Refuse to Comply with Electronic Visit Verification Requirements

Revision 25-5; Effective Dec. 1, 2025

People requesting or receiving personal attendant services are required to participate in Electronic Visit Verification (EVV) by allowing the attendant to use their home landline to report the start and the end of work. If a person does not have a home landline, or will not allow the attendant to use the home landline, the person must agree to an alternate device installation in the home. Failure to cooperate with EVV requirements can result in suspension or termination of services.

It is the caseworker’s responsibility to review the information on the rights and responsibilities form and adequately explain the EVV requirements to the applicant or person receiving services. It is important to communicate that a person’s failure to cooperate with EVV requirements can result in the suspension or termination of services. The caseworker must explain the following points:

• EVV is a phone and computer-based system that electronically verifies service visits occur and documents the precise time service provisions begin and end. The purpose of EVV is to verify that people are receiving the services authorized for their support and for which the state is being billed.
• EVV will not change the services the person receives.
• EVV is mandatory for all provider agencies and people receiving services from an attendant unless the person receives services through the CDS option.
• The attendant needs the person’s permission to use the home landline to call the toll-free number at the start and at the end of work. Under no circumstances should the person call the toll-free number on behalf of the attendant. If the person is asked to do this, they should report it to the provider agency.
• If the person does not have a home landline or does not want the attendant to use their phone, an alternative device can be placed in the home, which is used only to verify the attendant’s start and end of work. This device must always remain in the home. If the person notices the removal of the device, they should report it to the provider agency.
• If the person notices any other possible EVV violation such as an instance where the attendant leaves the home without providing services after calling the toll-free number upon arrival, they should report it to the provider agency.
• If the person has more questions, the caseworker refers them to the selected provider agency or Financial Management Services Agency (FMSA) for additional information on how EVV works.

For people using the CDS option, the caseworker must explain that the person receiving services, or a designated representative (DR), is the employer of record and can choose to use the EVV system or use paper time sheets. The three choices are:

• Full Participation-Phone and Computer: The CDS employee(s) use the phone portion of EVV, and the employer of record uses the computer portion of the system to perform visit maintenance.
• Partial Participation-Phone Only: This option allows the employer of record to participate in EVV but provides some help from the FMSA with visit maintenance. The CDS employee calls in when they start work and calls out when they end work. The employer uses a paper time sheet to document service delivery. The FMSA performs visit maintenance to make sure the EVV system matches the paper time sheets approved by the CDS employer.
• No EVV Participation: If the employer of record does not have access to a computer, assistive devices, or other supports, or feels they cannot fully participate in EVV, they may choose to use a paper time sheet to document service delivery.

The FMSA will require the employer of record to complete Form 1722, Employer’s Selection for Electronic Visit Verification (EVV), to indicate their choice.

If a person is refusing to cooperate with EVV requirements, it is considered a refusal to comply with service delivery provisions and policies in 2831, Suspensions Due to Refusal to Comply with Service Delivery Provisions. Some people whose provider is required to participate in EVV are not allowing the attendant to use their home phone and are also refusing to allow a Fixed Visit Verification (FVV) device to be placed in their home.

Providers are required to participate in EVV for services delivered by an attendant. People who refuse to allow the attendant to record hours worked through EVV, either through using their home phone or a FVV device, are non-compliant with their service delivery plan. These people are essentially not allowing the provider to carry out services per provider requirements.

2831 Suspensions Because of Refusal to Comply with Service Delivery Provisions

Revision 26-1; Effective March 1, 2026

The provider or caseworker may suspend services until an interdisciplinary team (IDT) meeting is scheduled and the situation is discussed. After the IDT meeting, the caseworker must send Form 2066-IDT, Interdisciplinary Team (IDT) Meeting Letter to the person within five business days that states services can be terminated if they do not comply with service delivery provisions. Form 2066-IDT also must state specifically what the person must do to continue services.

If the situation is not resolved and the person continues to refuse to comply, the caseworker convenes a second IDT meeting and sends the person a second Form 2066-IDT that states continued refusal to comply with service delivery provisions will result in the termination of services.

If the situation continues to be unresolved and a third situation arises, the caseworker convenes a third IDT meeting. They must send a third and final Form 2066-IDT to the person that states continued refusal to comply with service delivery provisions will result in the termination of services.

If the situation continues, the caseworker may send Form 2065-A, Notification of Community Care Services to terminate services. Review 2810, Individual Notification Procedures. A CCSE supervisor must approve denials based on a refusal to comply with service delivery. Document the conference and supervisory approval.

2832 Documentation of Compliance Issues

Revision 24-5; Effective Nov. 1, 2024

Documentation is required in all situations involving the person's refusal to comply with service delivery provisions. Opinions or evaluative conclusions are not appropriate documentation to substantiate a denial of services. Documentation should stress a factual statement of actions constituting noncompliance.

Determine and document if the person is aware of and able to understand the consequences of their or other's actions. If the person is not aware of their behavior or the behavior of someone in their home, discuss the issues with them.

Determine if someone seems to be abusing, neglecting or exploiting the person, and, if necessary, refer them to Adult Protective Services (APS). Continue services pending the APS investigation. APS may take appropriate action, such as obtaining a guardian to resolve the problem if the person is abused, neglected or exploited.

Document the date and content of each discussion with the following:

• person;
• interested family member;
• provider; and
• unit supervisor.

2833 Reauthorization of Services After Termination for Refusal to Comply

Revision 24-5; Effective Nov. 1, 2024

If a person's services were terminated because of refusal to comply with service delivery provisions that involve a provider, talk with the unit supervisor before sending a referral to another provider. You must discuss the person's particular compliance issues with a CCSE supervisor before reauthorizing services, and the unit supervisor must approve the referral.  Document the approval in the comments section of Form 2101, Authorization for Community Care Services.

Follow these steps when an applicant who was authorized services in the past had services terminated due to their failure to comply with service delivery provisions reapplies:

1. Before contacting the applicant, review the applicant’s circumstances of the previous denial and the steps to be taken for them with the supervisor. Document the review.
2. Review with the person or responsible party:
   • the reason for the previous termination;
   • the responsibility of the person or responsible representative to notify the provider and Texas Health and Human Services Commission (HHSC) about problems related to the service delivery provisions and the importance of good communication; and
   • that each task must be authorized, emphasizing that the only tasks the attendant is to perform are those authorized by HHSC.
3. Authorize services if the person agrees to follow the service delivery provisions.
4. Document the conversation with the person.
5. Contact the person or provider weekly for one calendar month to assess the person's compliance with service delivery provisions. If the person continues to have problems complying with service delivery provisions, contact the person and emphasize the need for them to comply.
6. If the provider complains about the person refusing to follow their service delivery provisions, contact the person monthly after the first month of service. Discontinue monthly contacts when complaints cease.
7. Terminate services if the person refuses more than three times to comply with service delivery provisions.

Review 2831, Suspensions Due to Refusal to Comply with Service Delivery Provisions.

2840 Threats to Health or Safety

Revision 25-4; Effective Sept. 1, 2025

A person or someone in their home may occasionally exhibit behavior that constitutes a threat to the health or safety of another person. Examples include, but are not limited to:

• exhibiting weapons;
• making direct spoken threats of physical harm, force or death;
• physically attacking a person with or without a weapon;
• threatening use of force by self or someone else;
• using or selling illegal drugs; and
• displaying dirty needles or the smell of toxic fumes from the manufacture or sale of illegal drugs in the person's home environment.

The caseworker must immediately notify management if a person or someone in their home exhibits threatening behavior or makes comments that are threatening, hostile or of a nature that would cause concern for the person, provider or Texas Health and Human Services Commission (HHSC) employee. Regional management must review these situations on a case-by-case basis and determine the most appropriate action to be taken. If the applicant's safety may be at risk, the caseworker must follow current policy about notification to the Department of Family and Protective Services Adult Protective Services (APS). If the caseworker believes there is a potential threat to others, regional management should determine the best method to notify the provider and address the person's needs without placing staff members at risk.

If a person threatens their own health or safety by threatening or attempting suicide or self-injury and is at immediate risk, call 911 to report the emergency. The situation also must be referred to APS. If the applicant or person seems to be abused, neglected or exploited by the person who threatens the health or safety of others, refer the person to APS.

Services should be suspended immediately in most cases that have a potential for danger.

The caseworker must send Form 2065-A, Notification of Community Care Services, by the next business day after receiving notice from the provider that services have been suspended for failure to comply or threats to health and safety. The notice must reference 26 Texas Administrative Code Section 271.155, state the last day services are delivered and include a clear statement in the comments that explains why services were suspended.

The caseworker must arrange an interdisciplinary team (IDT) meeting within three business days after becoming aware of the suspension to try to resolve the issue with the provider and the person. Depending on the severity of the reason for the suspension, some IDT meetings may be conducted by phone or some may require a face-to-face contact.

The caseworker may conduct the IDT meeting by phone or a face-to-face contact for all suspension reasons listed in this section. Caseworkers are required to discuss the specific case with their supervisors to determine the best approach for conducting the IDT meeting. Caseworkers must document the rationale for conducting the IDT meeting by phone.

During the IDT meeting, the caseworker, provider staff, the person and the person’s representative, if any, must evaluate the issue and discuss the program requirements for continued services. The IDT should identify any solutions to resolve the issue, including the person’s understanding of the issue and what must be done to resolve it. The caseworker must document the requirements for continued services. Review 2831, Suspensions Due to Refusal to Comply with Service Delivery Provisions, and 2832, Documentation of Compliance Issues, for more guidelines.

If the issue that leads to suspension is resolved during the IDT meeting, the provider must either implement the IDT recommendations or discharge the person within two business days after the IDT meeting. The provider also must refer the person to the caseworker for referral to another provider. The caseworker must notify the person in writing of the reinstatement of services. If services continue, assess if the person meets the guidelines for a person at risk. If the person meets those guidelines, follow procedures outlined in 2550, Identifying People at Risk. If the issue is not resolved and services cannot be continued, the caseworker begins the termination process.

2840.1 Monitoring or Annual Home Visit Delay Due to Unsafe Environmental Circumstances

Revision 24-5; Effective Nov. 1, 2024

The Texas Health and Human Services Commission (HHSC) caseworker is required to make every reasonable attempt to complete the Community Attendant Services (CAS), Primary Home Care (PHC), and Family Care (FC) service monitoring or annual reassessment visit. All attempts to contact the person must be documented to support the efforts to meet the requirements. In some situations, the caseworker cannot make the face-to-face home visit due to a dangerous environmental situation beyond the caseworker or person’s control. These situations may include but are not limited to:

• current police activity, a car chase, weapons drawn, drug raids;
• gathering of people on the streets demonstrating threatening or intimidating behavior directed at the caseworker; and
• illegal activities such as being close to the person’s home and occurring at the time the caseworker attempts the home visit.

When such situations occur and the caseworker feels threatened, they can make the home visit at another time. The caseworker must immediately notify regional management of their inability to conduct the home visit. The caseworker must schedule another service monitoring or annual reassessment visit at the earliest possible opportunity. The case must contain ongoing documentation of attempts to complete the visit and the reason for the delay until the monitoring visit has been completed.

If, during the home visit a person or someone in their home exhibits threatening behavior or makes comments that are threatening or hostile, the caseworker can end the service monitor or annual reassessment and reschedule for a later time. The caseworker must immediately notify regional management of their inability to conduct the home visit. The caseworker will refer to 2840, Threats to Health or Safety, to suspend or terminate services. If the threatening behavior is resolved, the caseworker must schedule another service monitoring or annual reassessment visit at the earliest possible opportunity. Document all attempts to complete the visit, along with any reasons for delays until the monitoring visit has been completed.

2840.2 Chronic Contagion or Infestation Conditions

Revision 25-4; Effective Sept. 1, 2025

While the chronic contagious medical condition or infestation of the person’s home may not pose an immediate danger to the health and safety of the person, provider agency staff or caseworker, either situation may adversely affect the health of anyone who supports the person’s services. These situations may pose a risk of exposing other people to the contagious medical condition or environmental infestation. Examples of unresolved chronic adverse medical or environmental-related condition(s) may include the presence of bed bugs, fleas, ticks, lice or scabies.

The caseworker must assess the person’s ability to comply with the request to eradicate contagions or infestations. The caseworker should exhaust all efforts to arrange for help to eradicate contagions or infestations based on the assessment of the person’s capabilities. The caseworker should identify available local resources that may provide the needed help to meet the person’s specific needs to resolve the risks associated with the spread of the contagion or environmental infestation to others.

Per 2831, Suspensions Due to Refusal to Comply with Service Delivery Provisions, the provider or caseworker may suspend services until an interdisciplinary team (IDT) meeting is scheduled and the situation is discussed. Efforts to identify local resources and natural supports to help the person, if any such resources and supports exist, should be well documented as part of the IDT meeting. Document any specific actions and responsibilities required of the person and other people, and a time frame agreed on to complete the eradication. Information from a pest control professional must be the basis for establishing a timeline for eradication, as each situation is unique. The specific actions and responsibilities required of the person or other people, such as family members or friends, who have agreed to provide support as part of the eradication plan, should be documented as service provision requirements.

If the eradiation plan is not followed and the situation is unresolved, the caseworker refers to 2830, Refusal to Comply with Service Delivery Provisions, and 2831 for guidance when the person is non-compliant with service delivery provisions.

The caseworker follows policy in 26 Texas Administrative Code Section 271.155, (f) Denial, Reduction or Terminations of Benefits.

2840.3 Active Tuberculosis (TB) Diagnosis

Revision 24-5; Effective Nov. 1, 2024

An applicant or person with a TB diagnosis cannot have services denied or terminated because of their disease.

The regional HHSC staff contacts their regional health department to ensure staff are linked to the right TB personnel to address TB cases on a case-by-case basis. The HHSC  caseworker may talk with their unit supervisor for help processing the case. They may use the Texas Department of State Health Services (DSHS) Public Health regions page to contact their regional health department. If the HHSC caseworker or supervisor cannot contact the local regional health department or needs more information, they may contact the DSHS TB and Hansen’s Disease Program staff linked to TB personnel in the county where the patient lives. The phone number is 512-533-3000 for general information and 512-533-3144 for the nurse administrator. Upon receiving the physician's report, DSHS assigns a representative to monitor the case through directly observed therapy. This process involves observation of the person taking their medication. It may also involve health-related training and the provision of more care of the person.

For cases with active TB, a team meeting should be set up to include the regional nurse, caseworker, provider and the local DSHS representative handling the case. These people ensure coordination of care and determine if special precautions need to be taken.

It is possible that DSHS will instruct HHSC to suspend the case while the TB remains active. If so, it will provide care for the person during this period. Most people become negative for TB within a few weeks of drug therapy.

Note: Refer to 1140, Disclosure of Information, about disclosure of information and national standards created under the Health Insurance Portability and Accountability Act to protect the confidentiality of individually identifiable health information.

2840.4 Sharing Information with New Providers Regarding Health and Safety Issues

Revision 24-5; Effective Nov 1, 2024

When services are suspended due to health and safety reasons, HHSC staff are required to convene an interdisciplinary team (IDT) meeting to resolve the issues. If the issues cannot be resolved, the provider may report it will no longer serve the person due to health and safety concerns.

In some situations, HHSC may terminate the person’s services due to health and safety issues. In other situations, HHSC may initiate services with a new provider. If the HHSC caseworker makes a referral to a new provider, they must determine how much information to share with the new provider about the previous actions.

The HHSC caseworker must share sufficient information with the new provider to avoid putting the provider at risk. This allows the provider to adequately plan for safely delivering services to the person, including selecting the appropriate service delivery staff and preparing the staff to handle situations that may arise. Providing information may avoid the issues that previously caused the termination or suspension.

Caseworkers must use good judgment to determine what information to share and, if in doubt, consult with their supervisors for guidance.

2841 Reinstatement of Services Terminated for Threats to Health or Safety

Revision 24-5; Effective Nov. 1, 2024

An applicant whose services were terminated in the past due to their or someone in their home being a threat to the health or safety of the client, department staff, or provider agency staff may be authorized services if the applicant signs Form H0003, Agreement to Release Your Facts, authorizing release of information, and:

(1) the applicant or person in home who posed the threat has been treated or is receiving treatment by a licensed or certified physician, psychiatrist, or psychologist and can furnish a letter saying that they are no longer a threat to themself or others;    
(2)the applicant or person in home allows a collateral contact with their physician, psychiatrist, or psychologist and the contact indicates that the applicant is no longer a threat to themself or others; or   
(3)the person in the home who posed the threat no longer poses the threat.

Complete the eligibility determination in the Service Authorization System Wizards within 30 calendar days after the date the signed application is received by the department. Review 2344, Rights and Responsibilities.

2841.1 Sharing Information on Previous Actions for Reinstatement

Revision 24-5; Effective Nov. 1, 2024

If a person who is previously terminated from services due to health and safety reasons reapplies for services and meets the requirements in 2841, Reinstatement of Services Terminated for Threats to Health and Safety, information may need to be shared with a newly selected provider.

If the HHSC caseworker makes a referral to a new provider, they must determine how much information to share with the new provider about the previous actions that resulted in termination of services. The caseworker must share sufficient information with the new provider to avoid putting the provider at risk and allow the provider to adequately plan for safely delivering services to the person. This includes selecting the appropriate service delivery staff and preparing the staff to handle situations that may arise. Providing information may avoid the issues that previously caused the termination or suspension.

Caseworkers must use good judgment to determine what information to share and, if in doubt, consult with their supervisors for guidance.

2910 People’s Right to Appeal and Request a Fair Hearing

Revision 25-2; Effective March 31, 2025

26 Texas Administrative Code (TAC) Section 271.155

(a) An applicant or person may request an appeal of any decision that denies, reduces, or terminates their benefits.
(b) A person is entitled to be notified 10 calendar days before any reduction or termination of their services, or to have the notification mailed 12 calendar days before the date of reduction or termination. If a person threatens their own health or safety or that of others, purchased services may be terminated without advance notice.

Inform the applicant or person in writing by sending Form 2065-A, Notification of Community Care Services, about their right to request a fair hearing if services are denied, reduced or terminated. A person may appeal their dissatisfaction concerning

• ineligibility for services;
• the tasks within a service;
• the amount or number of units of service the person will receive;
• the amount of the copayment for Residential Care; or
• the denial or termination of the priority status.

A person also may appeal when they request a new service or requests an increase in the number of tasks or units of service, and the request is not acted on within required time limits.

To request a hearing, a person may return Form 2065-A with a check mark in the appropriate box. The person may also make a verbal or written request for a fair hearing.

A person must request a fair hearing within 90 calendar days from the date of the action they want to appeal. To continue receiving benefits until the hearings officer gives a decision, the person must request the fair hearing before the effective date shown on Page 1 of Form 2065-A. In situations where services were terminated because of threats to the health or safety of another person, the person is not entitled to continued services even if appealed before the effective date shown on Page 1 of Form 2065-A. Review 2811, Effective Dates, and Appendix IX, Notification/Effective Date of Decision, for guidance on effective date of termination if the person is not entitled to continued benefits.

When a fair hearing is requested after the 90-calendar day period, HHSC staff may not prevent an applicant or person from filing an appeal because they believe the appeal was not requested within the required number of days. If a fair hearing request is received after 90-calendar days from the date of the notice, the caseworker must follow current procedures to file the appeal. The hearings office makes the decision about the person’s right to appeal.

The hearings officer is the final authority about the timeliness of appeal requests and accepts appeals filed after the time limit to determine if there was good cause for the delay in filing.

2911 Notice to the Provider for Continuing Services

Revision 25-5; Effective Dec. 1, 2025

If the person appeals before the effective date on Page 1 of Form 2065-A, Notification of Community Care Services, the caseworker must continue services at the current level pending the hearings officer’s decision unless denial is based on threats to health and safety. Review 2840, Threats to Health and Safety. The caseworker must complete a new Form 2101, Authorization for Community Care Services, in the Service Authorization System Online (SASO) to reinstate services at the current level within three business days after receipt of the request for a fair hearing. The caseworker sends Form 2101 to the provider to notify them to provide services at the current level until the hearings officer renders a decision. The Begin Date of services is the day after the termination date or reduction date on the previous Form 2101. The caseworker also sends Form 2067, Case Information, to inform the provider to reinstate services pending the hearings officer’s decision.

Example 1: At the annual reassessment, the caseworker determines that the Primary Home Care personal attendant services (PAS) hours must be reduced from 20 to 15 per week. The caseworker sends Form 2065-A to the person and Form 2101 to the Home and Community Support Services Agency (HCSSA) to notify them of the reduced hours. The person appeals before the effective date of the case action. The caseworker authorizes PAS at 20 hours per week until the hearings officer renders a decision.

When all services are terminated, such as at the annual reassessment when the person does not meet eligibility criteria, caseworkers must continue services at the current level when the person files an appeal before the effective date.

Example 2: At the annual reassessment, a Family Care person is terminated because of scoring 21 on Form 2060, Needs Assessment Questionnaire and Task and Hour Guide. The caseworker sends Form 2065-A to the person and Form 2101 to the provider to notify them of the termination of services. The person appeals before the effective date of the case action. The caseworker authorizes services at the same level as the previous Form 2101 authorization.

When the person submits a clear, written statement to request services stop during the appeal process, the caseworker sends Form 2067 to the provider with an effective date to stop service delivery. The caseworker does not send the person another Form 2065-A.

HHSC does not continue services during the appeal process if Medicaid eligibility has been terminated unless Medicaid eligibility is reinstated during the appeal period. Refer to 3441, Loss of Categorical Status or Financial Eligibility, and 2932, Coordination of Fair Hearings with MEPD Utilizing OES CRU, for procedures related to Medicaid terminations and continuation of services.

2912 Special Procedures for Denials of Community Attendant Services (CAS) People

Revision 25-2; Effective March 31, 2025

Denials of CAS people must be coordinated with both the HHSC regional nurse and with the Medicaid for the Elderly and People with Disabilities (MEPD) specialist. If the HHSC caseworker denies the person based on functional need, Form H1746-A, MEPD Referral Cover Sheet, must be sent to advise MEPD of the denial.

If the person appeals the denial, another Form H1746-A must be sent to MEPD advising that services will be reinstated pending the fair hearings officer’s decision. MEPD must also be notified on Form H1746-A when a decision is rendered.

If the change that prompted the request for an appeal on a Community Attendant Services decision occurred in the course of an annual reassessment, use Form 2067, Case Information, to notify the provider and the HHSC regional nurse. The HHSC regional nurse submits Form 2101, Authorization for Community Care Services, to reinstate services.

2913 Coordinating with Utilization Review for Fair Hearing Requests as a Result of Utilization Review Findings

Revision 24-3; Effective July 1, 2024

HHSC caseworkers must notify the utilization review (UR) nurse and UR regional manager when an applicant or person has requested a fair hearing because of UR findings for concurrent reviews.

Caseworkers must follow normal time frames and procedures for implementing UR findings following receipt of a UR tool indicating a case action is required. When the action is completed for an addition or increase in services or termination or decrease in services, the caseworker must send a notice to the applicant or person notifying them of the case action. The applicant or person has the option to appeal the case action indicated on the notice. Caseworkers must follow current policies and procedures for continuation of services pending an appeal.

If the applicant or person requests a fair hearing, the caseworker must inform the UR nurse who completed the review and UR regional manager by email that a fair hearing has been requested because of the UR findings. The caseworker completes Form H4800, HHSC Fair Hearing Request Summary, and sends the form to the Hearing Division and supervisor within three days of the request for a hearing.

On Form H4800, the caseworker lists the UR nurse, Agency Representative, UR regional manager, and Agency Representative Supervisor. The caseworker may be listed. The caseworker must confirm the correct UR nurse and UR regional manager to list on the form. The caseworker includes the UR nurse whose name is in Section A of the UR tool. The caseworker identifies the name of the UR regional manager by calling the UR nurse or calling the Utilization Management and Review (UMR) manager identified on the UMR website.

The designated data entry representative (DER) is responsible for uploading the caseworker’s fair hearing evidence packet in the Texas Integrated Eligibility Redesign System (TIERS) Fair Hearings and Appeals system. The evidence packet submitted by the caseworker will include the applicable notification form. If available, the caseworker includes the signed notification form returned by the applicant or person. The caseworker does not include any other documentation in the evidence packet.

The UR nurse and UR regional manager develop the fair hearing evidence packet to support the decision made by UR to change the services planned or delivered to the applicant or person. The evidence packet includes a summary of the UR findings and applicable Texas Administrative Code (TAC) rules and policy. The UR representative will upload the evidence packet in TIERS.

Form H4800-A, Fair Hearing Request Summary (Addendum), must be included as the cover sheet for each fair hearing evidence packet. The DER and UR representative must upload the fair hearing evidence packets in TIERS no later than 10 calendar days before the fair hearing date. The caseworker and UR nurse must forward a copy of the fair hearing evidence packets to the applicant or person no later than 10 calendar days before the fair hearing date.

The UR nurse, UR regional manager (optional) and caseworker participate in the fair hearing to admit the fair hearing packets into evidence and provide testimony about the case action.

2913.1 Concurrent Utilization Review When a Fair Hearing is Pending or a Decision Has Been Rendered

Revision 24-3; Effective July 1, 2024

The caseworker must inform the Utilization Review (UR) nurse when a case record is selected for concurrent review and a fair hearing is pending. The caseworker does not submit the case record for concurrent review. UR will replace the case with another randomly selected case record for concurrent review.

The caseworker must inform the UR nurse of the fair hearing decision details when a case record is selected for concurrent review and a fair hearing decision has been rendered during the current plan year. They do this by providing the UR nurse with a copy of the final order submitted by the hearings officer. The caseworker must provide specific information to the UR nurse about the service(s) appealed and the actions the caseworker took to implement the hearings officer’s decision. The caseworker submits the case record for concurrent review following current procedures. The caseworker will follow current policy and procedures for implementing UR findings.

2914 Withdrawal of an Appeal

Revision 25-2; Effective March 31, 2025

An appellant or appellant representative may request to withdraw their appeal verbally by calling the hearings office. A verbal request to withdraw may be accepted by the hearings officer’s administrative assistant or the hearings officer. HHSC staff should advise the appellant or appellant representative to speak directly to the administrative assistant or hearings officer. If the appellant or appellant representative contacts HHSC staff about the withdrawal, HHSC staff must contact the hearings office by conference call with the appellant or appellant representative on the line so the appellant or appellant representative may inform the hearings office of the withdrawal. If the appellant or appellant representative sends a written request to withdraw to HHSC staff, HHSC staff must forward this written request to the hearings office. A fair hearing will not be dismissed based on an HHSC decision to change the adverse action. All requests to withdraw the hearing must originate from the appellant or appellant representative.

If the appellant or appellant representative requests to withdraw their appeal within 14 calendar days of the fair hearing date, the hearings officer will notify HHSC by phone or email and open the conference line to inform participants of the cancellation. If the appellant or appellant representative requests to withdraw their appeal more than 14 calendar days prior to the fair hearing date, the hearings officer will indicate the withdrawal in the Texas Integrated Eligibility Redesign System (TIERS). A written notice will be sent to participants informing them of the fair hearing cancellation.

2920 Request for Increase in Services During an Appeal

Revision 25-2; Effective March 31, 2025

When services are reduced or terminated, such as at the annual reassessment, and the person files an appeal before the effective date of the reduction or termination, the caseworker must continue services at the current level until the hearings officer’s decision is rendered. If the person requests increased services pending the hearings officer’s decision, the caseworker cannot process the request. Within 14 calendar days of the request, the caseworker must send the person Form 2065-A, Notification of Community Care Services. They must explain the request for increased services is denied pending the hearings officer’s decision and may be reviewed for authorization once the hearings officer’s decision is rendered, if the person is determined eligible.

2930 Fair Hearing Procedures

Revision 25-2; Effective March 31, 2025

All fair hearings are processed through the Fair and Fraud Hearings section of the Appeals Division of the Texas Health and Human Services Commission (HHSC). The appeals division receives appeal requests from applicants and people contesting actions taken for benefits and services of various programs. These include the Supplemental Nutrition Assistance Program formerly known as the Food Stamp Program, Temporary Assistance for Needy Families, all Medicaid-funded services, and other agency programs required by state or federal law, or rules, to provide the right to a fair hearing. Hearings officers conduct hearings, consider evidence and issue decisions per rules, regulations and state and federal law.

Review the HHSC Fair and Fraud Hearings Handbook for specific information about the HHSC rules and requirements governing the fair hearings process.

2931 Processing Fair Hearing Requests Using TIERS

Revision 25-2; Effective March 31, 2025

When a request for a fair hearing is received from an applicant or person verbally or in writing, the Texas Health and Human Services Commission (HHSC) must refer the request to the hearings officer within five calendar days from the date of the request. Information is not mailed to the hearings officer but is entered into the Texas Integrated Eligibility Redesign System (TIERS) Fair Hearings and Appeals system by the designated data entry representative.

Upon receipt of the fair hearing request, the caseworker completes Form H4800, Fair Hearing Request Summary.

The caseworker sends Form H4800 to the Hearing Division and the supervisor within three calendar days of the request for a hearing. The three-day time frame allows the data entry representative two days to enter the information into the TIERS system. See the Form H4800 Instructions for specific directions for completion and transmittal.

Designated Data Entry Representative Procedures

Within two calendar days of receipt of Form H4800, the data entry representative enters the information into the Fair Hearings and Appeals system in TIERS. When the entry of all the information is completed, the system assigns the appeal identification (ID) number. The data entry representative will note the appeal ID number on the bottom of the form and in the designated space on the front of the form and send a copy back to the caseworker and supervisor.

HHSC Fair Hearings and Appeals Procedures

The TIERS system will generate a hearing packet which includes Form H4803, Notice of Hearing, and Form H4800. The caseworker and supervisor receive a copy of Form H4800 and the letter identifying the hearings officer assigned and information on the time and location for the hearing. It is the supervisor's responsibility to ensure that the caseworker or a designated representative participates in the hearing and is sufficiently prepared and knowledgeable about the case to represent the agency during the fair hearing process.

If Form H4800 has already been submitted into TIERS and there are subsequent changes such as address changes, participant updates, withdrawal forms or supporting documents needed for a fair hearing, the caseworker completes Form H4800-A, Fair Hearing Request Summary Addendum, with the updated information and submits it to the data entry representative.

The data entry representative must check TIERS for the fair hearings officer assigned to the case. If a fair hearings officer is not yet assigned, the data entry representative must wait until one is assigned to send the additional information. When sending information, the data entry representative completes the following activities according to the situation:

• When Form H4800-A is completed informing the fair hearings officer of address changes, participant updates and withdrawal forms, the data entry representative sends Form H4800-A directly to the hearings officer’s email address. The caseworker must enter the appeal ID number in the subject line.
• When the data entry representative submits supporting documentation for an appeal, they upload the information directly into TIERS and send the hearings officer an email with Form H4800-A attached. The caseworker must enter the appeal ID number in the subject line. The email must also inform the hearings officer that supporting documentation listed in Section 2 of Form H4800-A has been uploaded in TIERS. The caseworker and data entry representative must follow current time frames and procedures to ensure supporting documentation is uploaded into TIERS no later than 10 calendar days before the fair hearing date.

2932 Coordination of Fair Hearings with Access and Eligibility Services, Integrity Support Services Appeals and Mitigation

Revision 24-4; Effective Sept. 1, 2024

Texas Health and Human Services Commission (HHSC) Access and Eligibility Services (AES), and Integrity Support Services Appeals and Mitigation (A&M) handles all hearings for Medicaid for the Elderly and People with Disabilities (MEPD) and Texas Works staff (TW). A&M replaces MEPD and TW staff in specific steps for denying AES applications and ongoing cases and:

• represents HHSC AES in fair hearings;
• completes and implements all AES case actions based on fair hearing decisions; and
• coordinates required actions with AES staff and Community Care Eligibility Services (CCSE) staff.

The caseworker must coordinate all appeals with A&M, where AES staff determine financial eligibility. The caseworker must remember that A&M replaces AES staff in the following steps and to only send notices to AES staff if specified. All correspondence on appeals will go to the A&M supervisor and A&M administrative assistant.

People may appeal a decision verbally, in person or in writing. The caseworker must complete Form H4800, Fair Hearing Request Summary, to file the appeal through the Texas Integrated Eligibility Redesign System (TIERS) when a person requests a fair hearing. The method that the form is completed depends on the action being appealed. CCSE staff must determine if the appealed action is:

• a CCSE service denial which are denials based on a CCSE denial action or
• an AES financial denial which are denials based on an AES denial action.

If the appealed action is related to CCSE criteria other than an AES financial denial action, the caseworker completes Form H4800 and enters their name as the agency representative.

When the appealed action is an AES financial denial, the caseworker creates the appeal task in TIERS and A&M will process the appeal.

When the hearing officer renders a decision based on program criteria, the caseworker is notified by email of the decision. Based on the hearing decision, the caseworker determines the appropriate action per program specific time frames. The caseworker may need to coordinate an effective reinstatement date with A&M and must email the A&M mailbox. Per current procedures, the caseworker reports the implementation of the hearing decision through TIERS on Form H4807, Action Taken on Hearing Decision.

2933 Submitting the Appeals Evidence Packet

Revision 24-3; Effective July 1, 2024

When an applicant or person requests a fair hearing, the burden of proof to uphold the Texas Health and Human Services Commission (HHSC) decision rests with HHSC. The hearings officer is a neutral party and is restricted by law from presenting the agency's case. It is crucial that staff complete and organize all fair hearing packets to support the agency decision.

The Texas Integrated Eligibility Redesign System (TIERS) generates a hearing packet that includes Form H4803, Notice of Hearing, and Form H4800, Fair Hearing Request Summary. The caseworker and their supervisor receive a copy of Form H4800, the letter identifying the hearings officer assigned, and the time and location of the hearing. Staff or the designated representative participating in the hearing must be sufficiently prepared and knowledgeable about the case to represent the agency during the fair hearing process.

Each entity involved in the fair hearing is responsible for preparing its packet and forwarding the packet to both the:

• hearings officer identified on Form H4800; and
• appellant.

All documentation must be neatly and logically organized, and all pages numbered. Staff use Form H4800-A, Fair Hearing Request Summary (Addendum), to submit all supporting documentation to the hearings officer. The appeal identification number assigned by TIERS must be written on the top of Form H4800-A.

Provide the names, titles, addresses and phone numbers of all people or designees who will attend the hearing. Depending on the issue being appealed, the region may elect to send more staff such as the regional nurse or regional attorney. However, it is mandatory that the following staff attend:

• Medicaid for the Elderly and People with Disabilities (MEPD) or Centralized Representation Unit (CRU), for financial denials;
• caseworker or designee, for all case decisions; or
• Utilization Review nurse to the appeal action, if applicable.

All related documentation necessary to support the agency's decision must be sent by the data entry representative (DER) to the fair hearings officer as soon as possible, but by 10 calendar days before the hearing. Examples of additional information and who is responsible for submitting that information to the state fair hearings officer and appellant include, but are not limited to:

• the caseworker or designee:
  • Texas Administrative Code or policy handbook references about the case action;
  • summary of events;
  • a copy of any individual service plans, Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, or other official documentation forms including form instructions;
  • other documentation supportive of the decision, such as records of phone calls or visit summaries;
  • any relevant Utilization Review findings; and
  • a signed copy of the denial notification form and if available, use the signed form returned by the applicant or person when the appeal was filed;
• MEPD:
  • documentation supportive of the financial decision, including official documentation forms and phone calls; and
  • a copy of the original signed denial form returned by the member, if available and if unavailable, send unsigned copy;

Uploading the Appeals Evidence Packet into TIERS

All evidence packets must be scanned into the TIERS Appeals application using the process described below. The regional data entry representative (DER) uses Form H4800-A to submit all supporting documentation, also referred to as the appeals packet, to the fair hearings officer. The appeal identification number assigned by TIERS must be written on the top of Form H4800-A. The DER must upload the fair hearing evidence packet in TIERS by 10 calendar days before the fair hearing date.

The caseworker must provide the information to the DER by 12 calendar days before the fair hearing date, to allow enough time for the evidence packet to be submitted on time. The caseworker must:

• go to the multi-function HHSC Work Center and scan in the documentation;
• save the document by either allowing the default document name or entering a name of the user's choosing;
• retrieve the scanned document and attach it to an email; and
• send the document to the regional DER.

By 10 calendar days before the fair hearing date, the caseworker must forward a copy of the fair hearing evidence packet to the applicant or person requesting the fair hearing.

Within two business days after receipt, the DER must:

• save the attachment to the appropriate network drive, as assigned by regional management;
• go into the TIERS portal without launching TIERS and select the Appeals tab;
• ensure the appeal has been entered in TIERS, a requirement that must be met before the next step can be completed;
• select Hearing Evidence Packets Upload and enter the appeal identification;
• select Document Type: Agency Evidence Packet and note that items entered in any other selection will not be included in the evidence packet;
• select Validate;
• check the details to ensure the right person has been selected;
• browse for the document; and
• select Upload.

Users who make mistakes that cannot be reversed may contact the state office Document Maintenance manager to help correct the error and upload the appropriate information.

2934 Presentation of Evidence at the Fair Hearing

Revision 25-2; Effective March 31, 2025

Staff listed on Form H4800, Fair Hearing Request Summary, will receive Form H4803, Notice of Hearing, notifying participants when the hearing will be held. HHSC staff must adequately prepare both the fair hearing packet and presentation of evidence at the fair hearing. The burden of proof to uphold the agency's decision rests with the agency. The hearings officer is a neutral party and is restricted by law from presenting the agency's case.

Documentation contained in the fair hearing packet will not be considered in the decision unless the packet is offered into evidence. To accomplish this6tqy requirement, the agency representative must present the packet, ask that it be submitted as evidence and summarize what the packet contains.

Example: "I want to offer the following packet as evidence in the appeal filed on the behalf of Joe Smith. Pages 1-10 contain information about the completion of Form 2060, Needs Assessment Questionnaire and Task/Hour Guide. Pages 11-15 contain policy from the Community Care Services Eligibility Handbook, which relate directly to the issue in question. Pages 16-20 contain documents about individual rights. Page 21 has Form 2065-A, Notification of Community Care Services, mailed to the applicant on March 2, 2024."

The hearings officer usually can only consider the specific information offered in evidence when making the hearing decision. For example, the caseworker may clearly explain how the applicant must score 24 points on Form 2060 to be eligible for Primary Home Care. However, if documentation backing up that explanation handbook policy, Form 2060 instructions and appropriate appendices is not in the packet, the explanation will not be considered.

Verbal testimony may be considered only if read into the record and if the appellant agrees to allow it.

The hearings officer will ask the appellant if they received the evidence packet. If not, the hearings officer will attempt to determine why. If no effort was made to send a packet to the appellant, the packet may not be admitted and the appropriate agency representative will have to read information into the record to have it considered.

The hearings officer will then ask for objections and allow all admissible documents into evidence. Any documents admitted by the hearings officer may be considered when a decision is rendered. Specific items of importance on a page or policy section must be emphasized as the case is presented to ensure the case has been clearly presented. If any documents are not admitted, the hearings officer will explain the reasons for excluding the material.

2935 Action Taken after the Hearing Decision

Revision 17-1; Effective March 15, 2017

2935.1 Action Taken on the Hearing Decision for Reductions

Revision 25-2; Effective March 31, 2025

After the hearing is held, the Texas Health and Human Services Commission (HHSC) hearings officer sends a decision letter, Form H4807, Action Taken on Hearing Decision, to the appellant and sends copies to the caseworker and the supervisor. If the HHSC decision is sustained, then the caseworker takes the appropriate action. If services continued during the appeal period, then the caseworker completes a new Form 2101, Authorization for Community Care Services, and sends it to the provider with the reduced service amounts. The action must be completed within 10 calendar days after the hearings officer’s decision. It is not necessary to send the person another Form 2065-A, Notification of Community Care Services, since the person has already been notified of the change.

If the hearings officer reverses the decision, the hearings officer also sends HHSC Form H4807 and specifies the corrective action to be taken and a 10 calendar day time frame for the completion of the action. The caseworker continues authorization at the higher level of services. The caseworker sends the person Form 2065-A showing the new level of services. A new Form 2101 is not required, since the provider is already delivering services at the higher level. The caseworker actions required by the hearings officer must be reported back through the Texas Integrated Eligibility Redesign System (TIERS) within the 10 calendar day time frame designated by the hearings officer. Form H4807 is no longer completed and mailed back to the hearings officer. All communication will be through TIERS.

2935.2 Action Taken after the Hearing Decision of Terminations

Revision 25-2; Effective March 31, 2025

Once the hearings officer’s decision is rendered and if the person is determined eligible to continue receiving services, the caseworker sends Form 2065-A, Notification of Community Care Services, to the person to notify them that the hearings officer’s decision overturned the termination and their eligibility is continued. The caseworker includes the following statement in the comments: “The hearings officer has overturned the termination decision and you have been determined eligible for continued services effective the begin date.” The caseworker sends the provider an updated Form 2101, Authorization of Community Care Services, reinstating services.

If the hearings officer sustains the termination decision and services were not continued, then no further caseworker action is required on the case. If the hearings officer sustains the termination decision and services were continued, the caseworker must terminate services in Service Authorization System and send the provider Form 2101 ending services within 10 calendar days after the hearings officer decision, or per instructions provided by the hearings officer. The caseworker does not send another Form 2065-A to the person to provide notification that the person is not eligible based on the hearings officer’s decision. The caseworker verbally notifies the person of the termination of services and the effective date and documents the contact in the case record.

2935.3 Fair Hearings Officer Orders a New Assessment

Revision 25-2; Effective March 31, 2025

If the hearings officer’s final decision orders completion of a new Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, the hearing is closed because of this ruling. The caseworker must notify the person of the results of the new assessment on Form 2065-A, Notification of Community Care Services. The person may appeal the results of the new assessment. If the person chooses to appeal, the caseworker must show in Section 8, Summary of Agency Action of Form H4800, HHSC Action Taken on Hearing Decision, and also during the fair hearing that the new assessment was ordered from a previous fair hearing decision. If the person requests an appeal of the new assessment, HHSC continues services until the second fair hearing decision is implemented.

2935.4 Reporting the Action Through TIERS

Revision 25-2; Effective March 31, 2025

The caseworker completes Form H4807, Action Taken on Hearing Decision, recording case actions taken and sends it to the supervisor and the designated data entry representative. The caseworker must send Form H4807 within the time frames to allow at least two business days for the data entry representative to enter the information into the system. If the action cannot be taken within the time frame designated by the hearings officer, the caseworker must complete Section B on Form H4807 and send to the supervisor and data entry representative providing the reason for the delay. Acceptable reasons are listed on the form and the begin delay date and end delay date must be included. Review the form instructions for detailed information on completing Form H4807.

2936 Fair Hearing Exception Process

Revision 26-1; Effective March 1, 2026

HHSC staff must implement the fair hearings officer’s decision within the required time frame as soon as a fair hearing decision is rendered. This includes restoring any benefits or services as necessary.

If staff disagree with the outcome of a fair hearing, they must follow the established procedures to refer the issue to the regional director. Staff should use Form 1590, Request for a Fair Hearing Exception, to initiate this process, which documents their request for a review of the fair hearing decision.

If the regional director agrees to the staff’s request, they will forward Form 1590 to the Community Care Services Eligibility (CCSE) director or designee. This form must be submitted by the fifth calendar day following the date of the hearing decision. A copy of the form will be kept in a regional file and not in the case record.

Once the regional exception request is reviewed, the CCSE director or designee will decide if the request should be forwarded to the Fair and Fraud Hearings department for further consideration. In this process, the CCSE director or designee may:

• Agree with the regional assertion that the policy was misapplied and forward the form to Fair and Fraud Hearings.
• Determine that the hearings officer made a clear error of law or fact, resulting in a request for Fair and Fraud Hearings to review the case action. If Fair and Fraud Hearings concurs, they will issue a revised hearing decision.
• Disagree with the regional request, in which case the request will not be forwarded to Fair and Fraud Hearings.

If the CCSE director or designee decides to forward the exception request to Fair and Fraud Hearings, staff must mail Form 1590, Request for a Fair Hearing Exception to the applicant or person. Staff must place the exception request in the outgoing mail by the close of the next business day after receiving notification from the CCSE director. A copy of the exception request also must be placed in the case record.

The region will be notified of the decision about forwarding the request to Fair and Fraud Hearings. It is important to note that even if an exception request is submitted, the original hearings officer's decision must be implemented within the required time frame.

3110 Eligibility for CCSE Services

Revision 25-4; Effective Sept. 1, 2025

To receive Community Care Services Eligibility (CCSE), a client must meet income, resource, age and need criteria.

People who live in nursing homes are not eligible to receive CCSE services.

An applicant or person who lives in Texas may qualify to receive most CCSE services regardless of citizenship or the duration of residency. However, a person may not receive Community Attendant Services or waiver services without verification of citizenship and identity.

Provider agencies must accept HHSC's decision about which people are eligible. Visit 4000, Specific CCSE Services for eligibility requirements for specific CCSE services.

Note: Refer to Appendix XV, Services Available from Other State Agencies, for information about services that may benefit the applicant/individual.

Related Policy

26 Texas Administrative Code Section 271.51(a) 
26 Texas Administrative Code Section 271.51(b)

3111 Age Limits

Revision 25-4; Effective Sept. 1, 2025

A person must be 18 years or older or an emancipated minor to receive Community Care Services Eligibility (CCSE) services. However, a person of any age:

• may receive CCSE Medicaid-funded day activity and health services;
• who is not eligible for the Texas Health Steps program may receive CCSE Medicaid-funded Community Attendant Services (CAS).

Although age limits do not apply to Title XIX Day Activity and Health Services (DAHS), licensure prohibits service providers to deliver DAHS services in facilities that are not licensed to serve people younger than 18. No facilities currently licensed in Texas can serve non-adults.

Related Policy

26 Texas Administrative Code Section 271.61 
 

3120 Loss of Eligibility

Revision 25-4; Effective Sept. 1, 2025

A person is not eligible for CCSE services when the person:

• dies;
• is admitted to an institution;
• physician requests service termination for Medicaid services only;
• requests service termination;
• repeatedly refuses to accept help, except in an involuntary protective services case; or
• refuses to comply with their service plan.

The caseworker must notify the provider as soon as a person dies or enters a nursing home. Services are terminated effective the date of death or entry into the nursing home. The provider cannot bill for trying to deliver services after the effective date of the termination.

Related Policy

26 Texas Administrative Code Section 271.155(c) 


 

3210 Resource Limits

Revision 25-4; Effective Sept. 1, 2025

A person is not eligible for CCSE services if the value of nonexempt resources owned by them exceeds $5,000. A couple is not eligible for CCSE services if the value of nonexempt resources they own exceeds $6,000.

The individual limit applies to people who are single, even if they live with relatives. The individual limit also applies to people whose spouses live in different households. The couple limit applies to married people who live in the same household, even if the spouses are ineligible.

Include in the person’s resources what they own even if the resources are managed and controlled by someone else acting on their behalf. Also include funds that are not in the person’s name if those funds clearly belong to them and are available for use. Determine ownership based on the person’s statement unless contradictory evidence from another source exists.

Related Policy

26 Texas Administrative Code Section 271.89 

3220 Types of Resources

Revision 25-4; Effective Sept. 1, 2025

HHSC counts the following as resources to determine eligibility for CCSE services:

• Liquid resources include cash on hand, CDs, checking or savings accounts, money market funds, revocable trust funds, saving certificates, stocks or bonds. Liquid resources also include the person's or couple's portion of money in a checking or savings account, or a money market fund held jointly with another person.
  • Jointly held liquid resources are the resources of the applicant or person if they have unrestricted access to the funds, no matter the source. The applicant or person may move their portion of jointly held funds from a joint account to a new account. Although the new account may be jointly owned, all funds in the new account are considered the applicant’s or person’s.
  • Money received as a nonrecurring lump sum payment is only considered a resource 30 days from the date of receipt. Lump sum payments include, but are not limited to:   
    • income tax refunds;
    • earned income tax credits or rebates;
    • one-time bonuses from mineral rights;
    • retroactive lump sum Social Security, SSI or railroad retirement benefits;
    • lump sum insurance settlements;
    • one-time gifts, awards or prizes; and
    • refunds from rental or utility deposits. The applicant or person is responsible for reporting the receipt of a lump sum payment.
• Nonliquid resources include:
  • nonexempt licensed or unlicensed vehicles;
  • buildings and land not designated as homestead that are not producing income or are producing income less than 6% of the equity value; and
  • any other property not specifically excluded.

Evaluate nonliquid resources based on their equity value. Equity value is the market value of the resource minus any recorded encumbrances.

Money received from the sale of a countable or excluded resource, other than a homestead, is counted as a resource on the first day of the month following an entire month after it was sold. Example: The resource is sold on June 15 so proceeds are not counted until Aug. 1.

Annuities

A revocable annuity is a countable resource. If a person has an annuity, the caseworker must review the contract or agreement terms to determine if the principal is an available resource. Refer the annuity document to the regional attorney if there is a question about if the annuity is revocable.

Irrevocable annuities are not countable resources for Community Care Services Eligibility people. However, the purchase of an annuity may affect the person’s eligibility for institutional care or waiver services. If the person is concerned about the effect the annuity may have on future eligibility for services, refer them to consult with a Medicaid for the Elderly and People with Disabilities specialist.

Guardianships and Power of Attorney

If the person is a guardian for someone other than their spouse, do not include in their resources any separately identifiable funds that belong to the other person but are accessible to them as that person's guardian.

A person who has a financial power of attorney for another acts solely as a fiduciary agent. The fiduciary agent acts in a financial capacity, whether formal or informal, regardless of title, including representative payee, guardian or conservator. Therefore, assets that belong to the other person should not be considered as part of the person's available assets.

Assets held by a fiduciary agent for a person are considered available to the person unless otherwise excludable.

Related Policy

26 Texas Administrative Code Section 271.91 

3230 Resource Exclusions

Revision 25-2; Effective March 31, 2025

To determine eligibility for CCSE services, the department does not consider the following as resources. They are considered excluded for eligibility purposes. Any item not listed as an exclusion is considered a resource.

Homestead — Any structure used by the person as a residence, including other buildings and contiguous land. Mobile homes, houseboats, and motor homes are considered structures. Vacant property is not a homestead. Contiguous land means land adjacent to the home, including any land separated only by roads, rivers, and streams. Land is contiguous if it is not separated by property owned by another person. The homestead is excluded as a resource regardless of its location, even if the person no longer lives there unless they have purchased another residence. If they own two houses, their homestead is the property that they use as a residence. Only one homestead may be excluded for each person or couple.
If the person lives in a house, but also has a mobile home, houseboat or motor home on the property, these are all excluded as part of the homestead.

Personal property — Household goods and personal effects.

Property essential to employment — Tools and equipment required for employment or self-employment.

Prepaid burials — Prepaid burial arrangements, burial insurance, and burial plots. The cash surrender value of all life insurance.

Vehicles — One passenger car or other vehicle, such as a van or truck, used for transportation; or one unlicensed vehicle.

• A second vehicle may be excluded if it is:
  • specially equipped to enable a person with a disability to drive; or
  • essential to the employment or self-employment of the family.
• Any additional vehicles, licensed or unlicensed, are considered resources.

An inoperable junk vehicle can be assigned a value of $100, if the person's resources are less than:

• $4,900 for a single person; or
• $5,900 for a couple.

The caseworker must verify the value of an inoperable vehicle when the person's resources are within $100 of the CCSE resource limit $5,000 for a single person or $6,000 for a couple.

Income-producing property — Property that annually produces net income equal to or greater than 6% of the property's equity value. The equity value is the current market value of the property less any recorded encumbrances. Review 3231, Rate of Return on Income-Producing Property.

Installment contracts from mortgages, notes or loans — The value of installment contracts for the sale of land, other property, or repayment of loans, if the contract or agreement is producing income per fair market value at the time of the agreement. An installment is a mortgage or similar contract where the buyer promises to pay a fixed amount over a period until the principal of the note is paid. Even though the seller retains legal title, the property is not considered a countable resource if the buyer is fulfilling the contractual obligation. The payment is considered income.

Disaster assistance — Government payments granted for the rebuilding of homes destroyed or damaged in a disaster.

Reverse mortgages are treated as loans. The money received is not considered to be income. However, it is a resource the month after receipt.

Energy assistance — Payments or allowances for energy assistance made under any federal, state, or local law.

Supplemental Nutrition Assistance Program (SNAP) allotments — The value of SNAP allotments and USDA-donated foods.

Inaccessible resources — The cash value of resources that are inaccessible to the person. Examples are irrevocable trust funds, property in probate, and pension funds. Real property that the person or family is making a good faith effort to sell is exempt. The person or family must ask a fair price for the property, for its current market value. Property is also exempt if it is jointly owned and the other co-owners refuse to sell.

If jointly owned property is not excluded, the market value of the person's share of the property is countable. However, if the value will not affect eligibility, enter the full value of undivided property and document that the property is jointly owned.

An IRA should be treated as a pension fund, and therefore not considered as a resource for eligibility determination.

Mineral rights — The value of mineral rights.

Life estates and remainder interests — A life estate is the right a person has to property during the person's lifetime. A remainder interest is the right of ownership to the property when the life estate holder dies.

Replacement value of excluded resources — The replacement value of an excluded resource if it is lost, damaged, or stolen. The cash received from an insurance company for replacing the resource is not considered for three months if the resource is personal property or six months if it is real property. Any cash not spent within the specified period is considered a resource.

Monthly gross income — All income received monthly. Monthly gross income is counted as income in the month received and excluded as a resource in that month.

• Do not deduct income from resources unless the countable resources exceed $5,000 or $6,000 for a couple.
• If resources exceed the $5,000 or $6,000 limit, determine if the monthly income is included in the checking or savings account or cash on hand.
• If cash on hand is money remaining from the current month's income, it may be deducted unless this would duplicate deduction of the same money as a checking or savings account deposit.
• If resources exceed the $5,000 or $6,000 limit, deduct the amount of income the person may have received at the end of the month intended for the next month. Example: Next month's Social Security check arrives early (the last day(s) of the month) and is deposited into the person's checking or savings account.
• If income is deducted and the person receives Veterans Affairs (VA) aid-and-attendance or homebound benefits, deduct the full amount of VA payment even though aid-and-attendance is excluded from income.

Sale of a homestead — Proceeds from the sale of a homestead up to six months after they become available to the seller. The six months gives the person time to acquire another homestead. If they do so, any balance from the original sale must be considered as an available resource. If, before the end of the six-month period, the person declares that they have no intention of acquiring another homestead, the proceeds from the sale must be counted as an available resource.

Agent Orange Settlement Payments — Payments from the Agent Orange Settlement Fund or any other fund established in settlement of the Agent Orange product liability litigation.

Radiation exposure compensation — Payments received under the Radiation Exposure Compensation Act (P.L. 101-246).

Funds from the Transition to Life in the Community Program

Livestock

Earned income tax credit (EITC) refunds from the Internal Revenue Service

3231 Rate of Return on Income-Producing Property

Revision 17-1; Effective March 15, 2017

To determine whether the property is producing enough income to be excluded as a resource:

3310 Income and Income Eligibles

Revision 24-4; Effective Sept. 1, 2024

To be eligible for CCSE services, the person must either be:

• categorically eligible by receiving:
  • Supplemental Security Income (SSI);
  • Temporary Assistance for Needy Families (TANF);
  • Supplemental Nutrition Assistance Program (SNAP);
  • Medicaid, Specified Low-Income Medicare Beneficiary (SLMB) or Qualified Medicare Beneficiary (QMB) benefits; or
• income eligible means the person and their spouse's countable income must be equal to or less than the income limit set by the U.S. Department of Health and Human Services (HHS).

Categorical Eligibility for Title XIX Services

A person with full Medicaid is financially eligible for Title XIX services. These people are referred to as categorically eligible.

Use the Texas Integrated Eligibility Redesign System (TIERS) to determine the eligibility status of a person applying for Title XIX CCSE programs.

Related Policy

Categorical Eligibility, 2341.3
TIERS Inquiries, 7110
TIERS Type Program Chart, Appendix XIV

Categorical Eligibility for Title XX Services

Recipients of some non-Medicaid programs are financially eligible for Title XX benefits based on existing program eligibility. These people are referred to as having categorical eligibility for Title XX services.

Financial Eligibility Determination for Title XX Services

CCSE staff determine financial eligibility for applicants for Title XX programs unless financial eligibility has already been determined based on existing program eligibility. These people are referred to as income eligibles.

Related Policy

Determination of Countable Income, 3320
Budgeting Countable Income, 3330
Computation of Gross Income, 3340
TIERS Inquiries, 7110

Financial Eligibility for Community Attendant Services (CAS)

Medicaid for the Elderly and People with Disabilities (MEPD) or Texas Works (TW) staff determine financial eligibility for CAS. CCSE staff must not deny CAS cases based on income or resources, even if the applicant's assets seem to exceed the eligibility limits.

Effect of Living Arrangement on Financial Eligibility for Title XX Programs

If both spouses apply for services and only one spouse receives SSI, TANF, Medical Assistance Only, or another program that provides categorical eligibility for CCSE services, compare the total income of both spouses with the couple’s income limit to determine the second spouse's eligibility.

If a married person does not live with their spouse, use the individual income limit. Do not consider the income of the spouse unless that income or part of it is given to the person. Income diverted from a spouse in a nursing home to the person at home is included in the person's income calculation. If income diverted from a spouse in a nursing home makes a person ineligible, explain to the person that they can request the amount of income they keep from the institutionalized spouse may be reduced. If the amount they keep is reduced, they will be required to pay more to the nursing home. The person must contact MEPD to request this change. Explain that the person may need to reapply for CCSE, if the situation changes.

A CAS, PHC or Title XIX Day Activity and Health Services recipient who requests a Title XX service, is categorically eligible for Title XX services based on the current Medicaid eligibility certification.

Related Policy

Income and Resource Limits, Appendix XI

3320 Determination of Countable Income

Revision 25-4; Effective Sept. 1, 2025

Countable income is determined by totaling gross income from all the following sources, less all applicable exclusions and exemptions. Applicable exclusions and exemptions are specified in 26 Texas Administrative Code Section 271.55 and 271.59 of this title relating to Income from Excludable Sources and Income from Exempt Sources.

(1) Total gross earnings — This includes money, wages, commissions, tips, piece-rate payments, cash bonuses or salary received for work performed as an employee. This also encompasses pay for members of the armed forces including allotments from any armed forces pay received by a member of the family group from a person not living in the household.
(2) Self-employment income including farm income — For earned income to be considered self-employment, either the person or spouse must be actively involved or materially participating in producing the income.
(3) Social Security and railroad retirement benefits.
(4) Dividends — This consists of dividends from stocks or membership in associations and periodic receipts from estates of trust funds. These payments are averaged over a 12-month period.
(5) Rental income — This includes payments to the person from the rent of housing, store or other property, as well as from boarders or lodgers.
(6) Net income derived from oil, gas or mineral rights — This can include both lease and royalty payments. These payments are averaged over a 12-month period.

Reminder: Refer to 3330, Budgeting Countable Income, to determine if this income can be excluded as infrequent and irregular or as a lump sum payment.

(7) Income from mortgages or contracts.
(8) Public assistance or welfare payments — Temporary Assistance to Needy Families, Supplemental Security Income and general assistance such as cash payments from a county or city are included.
(9) Veterans' pensions and compensation checks — This may include money paid periodically by the Veterans Administration to disabled members of the armed forces or to survivors of deceased veterans, subsistence allowances paid to veterans for education and on-the-job training and refunds paid to ex-servicemen as GI insurance premiums.
(10) Educational loans, grants, fellowships and scholarships.
(11) Unemployment compensation — Unemployment compensation may be received from government employment insurance agencies or private companies during periods of unemployment and includes any strike benefits received from union funds.
(12) Workers compensation and disability payments — This includes compensation received periodically from private or public insurance companies for injuries incurred at work.
(13) Alimony.
(14) Regular monthly cash support payments from friends or relatives.
(15) Pensions, annuities and irrevocable trust funds — Payments may be paid to a retired person or their survivors by a former employer or by a union, either directly or through an insurance company. Periodic payments from annuities, insurance, irrevocable trust fund payments and civil service pensions are included.
(16) Income from the person's share of a life estate.

Related Policy

26 Texas Administrative Code Section 271.55

3330 Budgeting Countable Income

Revision 17-1; Effective March 15, 2017

The sources of income that may be included in the income eligibility budget fall into one of three categories: countable, excludable and exempt. Countable income is addressed in 3320, Determination of Countable Income. Treatment of the excludable and exempt income varies, as illustrated below.

3330.1 Excludable Income

Revision 25-4; Effective Sept. 1, 2025

Income may be fully or partially countable or may be excluded from the current eligibility budget. Excludable income will continue to be monitored by the caseworker at each financial review to determine how eligibility is affected. Excludable sources of income include:

• deductions from earned income, including Social Security payments, Medicare premium payments, bonds, pensions and union dues;
• the first $65 of a client's or couple's net earned income, plus half of the remainder;
• loans, grants, scholarships and fellowship funds obtained and used under conditions that preclude their use for current living costs.
  • any portion used to pay any other expense such as room, board or books cannot be excluded;
• Veterans Administration aid-and-attendance benefits, homebound elderly benefits and payments to certain eligible veterans to purchase medications;
• infrequent or irregular income, including income received less frequently than once a month, that averages $20 per month or less;
• one-third of the total amount of child support payments for an eligible child; and
• allowable exclusions from self-employment income, as indicated on the following chart.

Mandatory deductions from unearned income may also be excluded from the eligibility budget. Documentation  in the case record must clearly state that the deduction is mandatory and if or when the mandatory deductions will end.

For earned income to be considered self-employment, either the person or spouse must be actively involved or materially participating in producing the income. A business owner is determined to be materially participating if they meet any one of the following criteria. The owner:

• engages in periodic advice and consultation with the tenant, inspection of the production activities, and furnishing of machinery, equipment, livestock and production expenses;
• makes management decisions that affect the success of the enterprise;
• performs a specified amount of physical labor to produce the commodities raised and
• does not meet the full requirements above, but their involvement in crop production is still significant.

A blind or disabled student younger than 22 years who regularly attends school, college, a university or a course of vocational or technical training can have limited earnings that are not counted toward the income eligibility budget. This exclusion does not apply to unearned income.

The maximum amount of the income exclusion varies from year to year and is determined annually by the Social Security Administration (SSA). Exclusion amounts can be determined on the Student Earned Income Exclusion For SSI webpage.

Section 2002 of the American Recovery and Reinvestment Act of 2009 (ARRA) authorizes more unemployment compensation benefits of $25 per week for people who receive unemployment benefits. The added $25 is not countable income for either eligibility or co-payment purposes. As the added unemployment compensation may be included with the regular payment or as an added payment, a contact with the Texas Workforce Commission may be needed to determine if any of the payments are part of the ARRA added compensation.

Related Policy

26 Texas Administrative Code Section 271.57

3330.2 Exempt Income

Revision 25-2; Effective March 31, 2025

There are numerous exemptions on countable income. These exemptions can be found in Appendix XXX, Income and Resource Exemptions for Determining Financial Eligibility.

Exempt income is not included in the income eligibility calculation. Once identified and documented, caseworkers will not be required to monitor exempt income at subsequent financial redetermination. Sources of exempt income include:

1. Interest income.
2. Cash received from the sale of a resource which is a resource, not income.
3. Income of minor children who are supported by or dependent upon the client.
4. Refunds from the Internal Revenue Service for earned income tax credit.
5. Reimbursement from an insurance company for health insurance claims.
6. Any cash from a non-governmental medical or social services organization if the cash is:
   • for medical or social services already received by the person and approved by the organization, and which is not more than the value of those services; or
   • a payment restricted to the future purchase of a medical or social service.
7. Proceeds of either a commercial loan or an informal loan, when repayment is required with or without interest. The proceeds amount borrowed are not counted as income in the month they are received but are considered a resource in the following month(s). To claim exemption from the proceeds of a loan, a person must prove that they acknowledge an obligation to repay and that some plan for repayment exists. If these conditions can be verified, no written contract is required.
8. The amount of the cost-of-living increase in any pension or benefit, received on or after Jan. 1, 1985, that would cause the person to be ineligible for continued services. This exclusion applies only to community care people who are already receiving services or case management and would become ineligible because of the increase. It does not apply to applicants.
9. In-kind income, such as food, clothing, shelter, rent subsidies.
10. One-time or lump-sum payments from any source.
11. Funds from the Transition to Life in the Community Program.

For a complete list of income exemptions, review Appendix XXX.

The term lump sum, as listed in 10 above, can be defined as income that is not expected to recur with a predictable pattern of frequency.

Income received less than three times per year that does not meet the $20 monthly average requirement, as listed in 5 above, should be treated as a lump sum payment. If the lump sum could affect eligibility, the case should be monitored 30 calendar days following receipt to ensure that resource eligibility is not affected.

3340 Computation of Gross Income

Revision 25-2; Effective March 31, 2025

If a person receives gross income more than monthly, compute the income as follows.

• Weekly income — multiply by 4.33
• Bi-weekly income — divide by 2 and multiply by 4.33
• Twice monthly income — multiply by 2.

3341 Income Averaging

Revision 25-2; Effective March 31, 2025

Calculate the income average of all income that may be received monthly but is usually received less often. The caseworker also may need to calculate the 12-month average income for monies received for seasonal employment, such as agricultural or construction work.

If a person ends regular employment to accept seasonal employment but later returns to the regular job, calculate the income average from the combined sources over the 12-month period.

3410 Verification of Public Assistance Status

Revision 24-4; Effective Sept. 1, 2024

Within 24 months of the last financial review, verify the correct categorical financial status of current:

• Temporary Assistance for Needy Families (TANF);
• Supplemental Security Income (SSI);
• Qualified Medicare Beneficiary (QMB);
• Specified Low-Income Medicare Beneficiary (SLMB);
• Qualifying Individuals (QI);
• Supplemental Nutrition Assistance Program;
• Medicaid Buy-In; or
• Medicaid people; and
• certify eligibility on this basis.

Place a dated copy of both Form 2064, Eligibility Worksheet, from Service Authorization System Online (SASO) and a Texas Integrated Eligibility Redesign System (TIERS) inquiry in the person's case folder. This will satisfy verification requirements for a person receiving service(s) based on categorical financial status.

Refer to 7110, TIERS Inquiries, for a full listing of programs that provide categorical eligibility for Community Care Services Eligibility programs.

3420 Verification of Income and Resources

Revision 26-1; Effective March 1, 2026

Program Standard: The caseworker must accurately establish the countable amount of income and resources. This determines the income-eligible applicant's financial eligibility.

Determine the amount of countable assets for people who apply as income eligibles. Financial eligibility must also be redetermined for these people within 24 months of the last financial review. A person's declaration of income and resources for all programs is acceptable, excluding waiver services unless:

• There is reason to doubt the reliability of the applicant's statement. The caseworker can request verification whenever any doubt exists.
• The applicant's declared resource amount is within $100 of the resource eligibility limit.
• The applicant's declared income amount is within $10 of the income eligibility limit.
• The applicant seems unsure about the amount of income or resources available. The caseworker may accept a certain level of uncertainty. Example: The person may state they receive about $350 per month. Since this is well below the income eligibility cap, the applicant's statement may be accepted even though the person is not sure about the amount. However, if the applicant responded with somewhere around $1,500, it would be necessary to verify the amount of income, given the uncertainty and the proximity to the eligibility limit.

If a person meets the criteria in 3430, Eligibility Before Verification, refer the person for services before verifying income and resources. Complete the verification within 30 calendar days of the application.

Applicants must provide all income and resource data needed to establish eligibility. Ask the applicant or responsible party to provide the information required to verify income and resources.

Give the applicant or responsible party a specific due date when information is requested. Explain the result of not providing the requested data. During a review, make the due date two weeks before the day the current certification period ends. This allows a few more days to give the person a second chance before terminating services effective the last day of certification. Follow up at least once before denying the applicant for failure to cooperate.

During a financial review, if a person reports closing a bank account or no longer having an account included in the last review, and adding the last known balance would bring the person to within $100 of the resource eligibility limit, verify with the bank that the account has been closed.

If the information can be obtained by making a phone call or mailing a verification form, attempt to get the data before denying the application. If the caseworker cannot get the information and the applicant does not provide it, deny the application. If the caseworker cannot get information needed for a financial recertification and the person does not provide it, send Form 2065-A, Notification of Community Care Services, at least 12 calendar days before termination becomes effective.

Without verifying the income or resources, the caseworker may deny an application because the person reports excess income or resources. Explain the reason for the denial to the person or responsible party. Select statement of client or responsible party as the verification type for income and resources, as applicable, in the Service Authorization System Online (SASO) financial wizard. 

Review Appendix XII, Examples of Methods to Verify Income and Resources, for methods to verify data. The caseworker may use a verification source not listed in Appendix XII if they determine the source is both knowledgeable and objective. A person is considered knowledgeable if they routinely assess values on that type of resource in the area where the resource is located. A person may not be considered objective if they have a vested interest in the person’s eligibility.

Information on Form 2064, Eligibility Worksheet, should contain enough data to determine what, when, where and how the applicant's or person's income and resources were verified and traced to the original source. For categorically eligible applicants and people with Temporary Assistance for Needy Families (TANF), Medical Assistance Only (MAO), Supplemental Security Income (SSI), Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB), Qualifying Individual (QI) and the Supplemental Nutrition Assistance Program, the case record must:

• show that categorical status was verified; and
• include a printed copy of a Texas Integrated Eligibility Redesign System (TIERS) inquiry that shows the applicant's categorical status.

Form 2064 must show that verifications were received before the date eligibility rules were processed. 

3421 Financial Documentation Requirements

Revision 24-4; Effective Sept. 1, 2024

This chart is designed to help determine what is required for financial eligibility documentation.

3422 Exceptions to Verification Requirements

Revision 26-1; Effective March 1, 2026

Income eligible people must complete a new Form H1200, Application for Assistance – Your Texas Benefits, within 24 months of the initial financial determination. The date of application is the date Health and Human Services Commission (HHSC) receives the application. This date must be entered in the Financial Wizard in Service Authorization System Online (SASO). Subsequent financial redeterminations will not require completion of Form H1200, unless the caseworker thinks the person’s financial eligibility may be in question.

Even though a new Form H1200 is not needed, the caseworker must still contact the person and confirm that significant changes in income and resources have not occurred.

If a new source of income or a new resource is at a financial review, reverify all the person’s resources. If adding the person’s new assets to existing income or resources brings the total income within proximity of financial eligibility limits, reverify all the person’s resources.

Following these guidelines at a review, the caseworker may need to verify:

• both income and resources,
• income but not resources,
• resources but not income, or
• neither income nor resources.

If a person loses categorical eligibility between reviews, for example, they stop receiving Temporary Assistance for Needy Families or the Supplemental Nutrition Assistance Program, that person may be able to continue receiving services without a financial review until the next financial review is due. Review 3441, Loss of Categorical Status, for more information. If the person or caseworker reports income and resources within eligibility limits and no other information exists to contradict this report, the person may continue to receive Title XX, block grant services. In this case, the caseworker must verify both income and resources at the next financial review.

3430 Eligibility Before Verification

Revision 25-4; Effective Sept. 1, 2025

A Medicaid-certified applicant for CCSE-purchased services who requires a verbal referral is eligible to receive CCSE-purchased services when their eligibility for Medicaid is verified. A non-Medicaid certified applicant who meets the requirements for a verbal referral is eligible to receive CCSE purchased services while income and resources are verified. Visit 1130, Definitions, and 2631, Negotiated Referrals.

To be eligible, this applicant must:

• be a new applicant for CCSE services;
• appear to be eligible based on the declaration of income and resources on their application for services or to have possession of a current medical care identification card; and
• meet the age and need criteria for the CCSE service he requires.

The eligibility period for non-Medicaid applicants begins on the date of application.

A non-Medicaid applicant must provide the information needed to verify their income and resource amounts to continue receiving services. This must be done within 30 days of the application date.

If, pending financial eligibility verification, the non-Medicaid applicant appears eligible for immediate service initiation, use the following procedures as appropriate.

1. Refer the applicant to the provider per 2631.
2. On Form 2101, Authorization for Community Care Services, enter the earliest date negotiated with the provider as the date services begin.
3. If the applicant is determined ineligible within the 30-day verification period, or if the applicant does not provide the information needed to verify income and resource amounts by the 30th day, send Form 2065-A, Notification of Community Care Services, to the person to terminate services 12 days after the Form 2065-A date. Refer to Appendix IX, Notification Effective Date of Decision.

Related Policy

26 Texas Administrative Code Section 271.151(g)

3440 Changes in Financial Circumstances

Revision 25-4; Effective Sept. 1, 2025

The person must promptly report any changes in:

• income, resources or family size;
• loss of assistance grant or Medicaid benefits; or
• other changes in functional ability or circumstances that affect eligibility.  

The person is subject to fraud prosecution if they willfully fail to report changes and continues to receive services for which they are not eligible.

People must promptly report any changes in income or resources. Note in the case record, but do not verify, reports of changes in income or resources that do not affect eligibility. Newly acquired resources that may affect eligibility, such as an inheritance that involves property, are disregarded for 30 days from the date received. After 30 days, determine the amount of resources and terminate the person’s eligibility if the amount exceeds the resource limit.

Related Policy

26 Texas Administrative Code Section 271.153(f)

3441 Loss of Categorical Status or Financial Eligibility

Revision 24-4; Effective Sept. 1, 2024

If a Community Care Services Eligibility (CCSE) person temporarily loses categorical or financial eligibility for Title XIX services, CAS, PHC and DAHS, the caseworker must contact the person or the appropriate agency to determine the reason for the denial and if reinstatement is likely.

If the person loses Medicaid eligibility because their Supplemental Security Income (SSI) is being denied, the caseworker must contact the person or the Social Security Administration (SSA) to determine the reason for the denial and if the person may be reinstated without a break in coverage.

Caseworkers may receive a copy of a denial notice or the monthly Loss of Eligibility Report for eligibility for the following programs:

• Community Attendant Services (CAS)
• Medicaid Buy-In (MBI)
• Medicaid through Temporary Assistance for Needy Families (TANF)
• Categorical eligibility through the Supplemental Nutrition Assistance Program (SNAP)
• Qualified Medicare Beneficiary (QMB)
• Specified Low-Income Medicare Beneficiary (SLMB)
• Qualifying Individual (QI)
• Medicaid through Type Program (TP) 03 (Pickle), TP 18 (Disabled Adult Children), TP 19 (SSI Denied Children) or TP 22 (Widow /Widower).

When the caseworker learns about the denial, they must check the Texas Integrated Eligibility Redesign System (TIERS) to verify the denial and the reason. The caseworker must contact the person to discuss the situation and if feasible, help the person complete the actions necessary for reinstatement of eligibility. If the person has been denied on failure to furnish information, the caseworker must contact the person as soon as possible to advise them of the loss of service and the necessity of providing the information required by Medicaid for the Elderly and People with Disabilities (MEPD) or TANF. The caseworker may also contact the MEPD or TANF specialist involved, ask about the person's current income and resource amounts, and if reinstatement will occur.

3441.1 Procedures Pending Reinstatement

Revision 25-4; Effective Sept. 1, 2025

Suspension Pending Reinstatement

The caseworker may suspend services for 60 calendar days to allow a determination on the person’s Medicaid status to be made for the reinstatement of services. Within four business days of determining suspension is appropriate, the caseworker prepares  Form 2065-A, Notification of Community Care Services, checks the Notification of Ineligibility or Termination of Benefits, the date services end and notes that services are suspended pending reinstatement of Medicaid or financial eligibility, as applicable. The caseworker sends the completed Form 2065-A to the person within that time frame and also sends Form 2067, Case Information, to the provider to suspend services effective the date of Medicaid denial.

During the period when services are temporarily suspended by Medicaid, all case actions for CAS, PHC and Title XIX DAHS such as monitoring and annual visits, changes and transfers will be suspended. However, the caseworker must set a special review for the 60th day following the suspension to check if eligibility has been re-established.

If at any time during the initial 60 calendar day period the caseworker learns that eligibility has been reestablished, they have 14 calendar days to:

• call the provider to negotiate the earliest date for services to resume;
• follow up the phone call with Form 2067 to the provider and note reinstatement of services with the negotiated date;
• make any 90-day monitoring or annual reassessment visits which would have occurred during the suspension;
• document the reinstatement of eligibility and the reason for delay in monitoring or annual reassessment visits because of the suspension of services; and
• send the person Form 2065-A stating the negotiated date services are to resume. This must be documented in the comments section.

If eligibility is not reestablished on the 60th day, the caseworker may extend the temporary suspension for another 30 calendar days for a total of 90 calendar days if the caseworker determines the person may still have eligibility reinstated. This decision is established based on research of MEPD case-specific information. At any time during the added 30 calendar days the caseworker learns eligibility has been reinstated, they have 14 calendar days to resume services. Caseworkers must send Form 2067 to the provider to have services resumed. They also must make any 90-day monitoring or annual reassessment visits that would have occurred during the suspension. The caseworker documents the reinstatement of eligibility in the case record and the reason for the delay in monitoring or annual reassessment visits because of the suspension of services. The caseworker sends the person Form 2065-A with a statement that services have been reinstated.

Family Care During Suspension

While the person is working on reinstatement, the caseworker explores transferring the person to Family Care (FC). If the region does not have open enrollment, review 2231.1, People Who May Receive Title XX Services with Regional Director Approval, to determine if the person meets the bypass criteria. No one may bypass the FC interest list during times of extreme budget limitations on a regional or statewide basis.

If the person will be transferred to FC, the change must be processed within 14 calendar days of learning of Medicaid denial. If person is not categorically eligible, record the self-declared income and resources in the case record. Update the Service Authorization System Online (SASO) to show the person as income eligible. It is not necessary to get Form H1200, Application for Assistance – Your Texas Benefits, from the person or to verify income and resource amounts until the next financial review is due.

Submit Form 2101, Authorization for Community Care Services, to transfer a person from PHC or CAS to FC. Use the comments section on Form 2101 to document the person’s services being transferred from PHC or CAS to FC because of a loss of Medicaid. Enter the day after the last date of Medicaid coverage as the from date on Form 2101. If the Medicaid denial is unknown until after the last day of Medicaid coverage, use the earliest date FC can begin as the from date.

The caseworker must send F2065-A, Notification of Community Care Services within two business days to notify the person of the CAS or PHC suspension and the transfer to FC pending reinstatement of financial eligibility for CAS or PHC.

When Medicaid is reinstated and the person is transferred back to PHC or CAS, all pre-initiation activities, including a new Form 3052, Practitioner's Statement of Medical Need, is required. Review 4673.6, Temporary Loss of Eligibility and Reinstatement Procedures.

If the person fails to cooperate with the financial reinstatement process, the person cannot remain on FC. The caseworker must send Form 2065-A to deny FC services. The 2065-A denial date must allow for 12 days adverse action.

Denial Because of No Reinstatement

If reinstatement of eligibility is not granted, the caseworker sends the person Form 2065-A denying services. The date of denial is based on the:

• Medicaid eligibility end date, shown in the Texas Integrated Eligibility Redesign System (TIERS); or
• denial date on Form H4808, Notice of Change in Applied Income/Notice of Denial of Medical Assistance, from MEPD.

Send Form 2101 to the provider on the same date and note that services are denied effective the date of the financial denial.

Other Title XX Services During Suspension

If the person is receiving Title XX services, Emergency Response Services (ERS), Home Delivered Meals (HDM) or Title XX Day Activity Health Services (DAHS), continue the same authorization during the Medicaid suspension.

All case actions including financial reassessment, functional reassessment and monitoring for ERS, HDM or Title XX DAHS must continue during the CAS, PHC or Title XIX DAHS suspension period.

3441.2 Reinstatement Procedures After Denial

Revision 25-2; Effective March 31, 2025

If financial or categorical eligibility is re-established within 60 calendar days of the denial date and the person reapplies for services, the caseworker may use the information currently on file to determine eligibility. Completing new forms will not be required, except for a new Form 2110, Community Care Intake, and Form 2101, Authorization for Community Care Services. The caseworker must note in the Comments section of Form 2110 that reinstatement procedures are being used within 60 calendar days of the denial date and may use the following forms currently on file:

• Form 2059, Summary of Client's Need for Service
• Form 2060, Needs Assessment Questionnaire and Task/Hour Guide
• Form 2307, Rights and Responsibilities
• Form 1584, Consumer Participation Choice

The caseworker must contact the person and review the functional assessment, including Form 2060 and Form 2059, to determine if there have been any changes in the person's physical condition or needs. If Form 2060 is over one year old, if there have been changes in the person's condition or needs or if the person has difficulty communicating by phone, the caseworker must make a home visit to review or revise the assessment. Initial eligibility time frames will apply.

The caseworker must send an initial referral packet and initial Form 2101 referral to the selected provider. For Primary Home Care and Community Attendant Services, the provider must complete all pre-initiation activities, including getting a new Form 3052, Practitioner's Statement of Medical Need.

4110 Description

Revision 25-2; Effective March 31, 2025

Adult Foster Care (AFC) provides a 24-hour living arrangement in a Texas Health and Human Services Commission (HHSC) contracted foster home for people who, because of physical, mental or emotional limitations, cannot continue independent functioning in their own homes. Services may include meal preparation, housekeeping, minimal help with personal care, help with activities of daily living and provision of or arrangement for transportation. The unit of service is one day.

Providers of AFC must live in the household and share a common living area with the person. Detached living quarters do not constitute a common living area. The person enrolled to provide AFC must be the primary caregiver. Providers may serve up to three adult people in an HHSC enrolled AFC home without licensure as a personal care home.

4111 Four Bed Adult Foster Care Homes

Revision 25-2; Effective March 31, 2025

A Type C Assisted Living license is obtained if the provider wants to serve four people. The home cannot be approved for the fourth person until the provider has applied for and received the Type C license. After the enrollment is complete, the provider may apply for a Type C license from the Texas Health and Human Services Commission Regulatory Services Division. The license must be renewed yearly and requires an annual fee.

4112 Small Group Homes

Revision 25-2; Effective March 31, 2025

Adult Foster Care (AFC) may also be provided in a small group home licensed by the Texas Health and Human Services Commission (HHSC) as Assisted Living Type A, Small, under the Minimum Licensing Standards for Assisted Living. The provider must submit a copy of the Assisted Living license to contract management staff before enrollment and upon renewal thereafter. The provider must report to contract management staff any problem(s) identified by Regulatory Services. HHSC regional contract managers enroll small group homes and providers must meet all applicable requirements in the Minimum Standards for AFC. Providers must serve no more than eight adult people in an enrolled small group home.

AFC provided in small group homes is subject to two sets of regulations, HHSC minimum standards for AFC and Licensing Standards for Assisted Living Facilities. The stricter requirements apply when requirements conflict. Therefore, an enrolled AFC provider whose home is licensed as a small group home must comply with the requirement that an attendant is always present when residents are in the facility. This requirement applies regardless of the number of people currently living in the facility.

4113 Contract Manager and Case Worker Responsibilities

Revision 17-1; Effective March 15, 2017

4113.1 Contract Manager Responsibilities

Revision 25-2; Effective March 31, 2025

Texas Health and Human Services Commission regional contract managers are responsible for all requirements for adult foster care (AFC) providers and homes. The contract manager's responsibilities include:

• recruiting adult foster homes;
• processing AFC applications;
• orientating and training the provider;
• conducting fire and health inspections;
• disenrolling adult foster homes;
• approving private pay people;
• conducting administrative reviews;
• reassessing the provider and home; and
• processing payments.

4113.2 Case Worker Responsibilities

Revision 25-2; Effective March 31, 2025

Texas Health and Human Services Commission (HHSC) caseworkers are responsible for all requirements for adult foster care (AFC) applicants and people. The caseworker's responsibilities include:

• completing the AFC applicant intake and assessment process;
• determining financial and functional eligibility for AFC;
• assessing appropriateness for AFC;
• providing information to interested applicants about potential adult foster homes and arranging visits to the homes;
• developing a service plan and completing the person’s provider agreement;
• authorizing AFC services;
• monitoring the person; and
• processing changes and conducting annual reassessments of the person.

4120 Eligibility

Revision 17-1; Effective March 15, 2017

4121 Basic Eligibility

Revision 25-2; Effective March 31, 2025

To be eligible for adult foster care (AFC), applicants and people must meet basic eligibility requirements for Community Care Services Eligibility services as well as specific requirements related to AFC. Find these requirements in 3000, Eligibility for Services.

4122 Appropriate Characteristics for Adult Foster Care

Revision 25-2; Effective March 31, 2025

Applicants and ongoing people in adult foster care (AFC) must display appropriate characteristics for AFC placement.

AFC placement is not appropriate for all people. Form 2330, Assessment and Service Plan Approval for Adult Foster Care, must be completed for all applicants. If any inappropriate characteristics are identified, the applicant or person is not appropriate for AFC and cannot be authorized for services.

A new Form 2330 must be completed at each annual review to ensure the person’s needs can be met within the foster care setting.

4123 Supervisory Approval

Revision 25-2; Effective March 31, 2025

It is the supervisor's responsibility to ensure that the applicant or person meets the appropriate characteristics, and their needs can be adequately met in adult foster care (AFC). The supervisor indicates on Form 2330, Assessment and Service Plan Approval for Adult Foster Care, if AFC is approved or disapproved. Supervisory approval is required before AFC is authorized or to reauthorize.

Review 3000, Eligibility for Services, for additional eligibility requirements.

4130 Adult Foster Care Intake and Assessment

Revision 25-2; Effective March 31, 2025

Adult Foster Care (AFC) is appropriate for people who, because of physical, mental or emotional limitations, cannot continue independent functioning in their own homes and who need and desire the support and security of family living. AFC is also appropriate for people who do not need institutional care but cannot resume independent living or have no relatives who are able to provide a home.

4131 Response to Request for Services

Revision 25-2; Effective March 31, 2025

Once an intake for adult foster care (AFC) is received, the caseworker arranges a home visit to conduct the assessment based on the intake priority. Refer to 2340, The Initial Interview and Application Process, for complete procedures. During the home visit, the caseworker assesses the applicant for financial eligibility and functional eligibility, using Form 2060, Needs Assessment Questionnaire and Task/Hour Guide. They also complete Form 2330, Assessment and Service Plan Approval for Adult Foster Care, to determine if the applicant is appropriate for AFC. Form 2330 lists the appropriate and inappropriate mental and physical characteristics for AFC people.

AFC is not appropriate and should not be authorized for a person who:

• requires considerable help with personal care due to physical or mental conditions;
• requires long-term care in a medical or psychiatric facility;
• is a danger to themself or others; or
• is bedfast.

4132 Person’s Rights and Responsibilities

Revision 25-2; Effective March 31, 2025

The caseworker must explain the room and board requirements in adult foster care (AFC) and ensure that the applicant understands that they must pay a portion of their monthly income for room and board. Review Form 2307, Rights and Responsibilities, and Attachment 2307-F, AFC Rights and Responsibilities, with the applicant. Make sure the person understands their responsibilities as a resident in an AFC home.

4133 Assessing Potential Adult Foster Care Homes

Revision 25-2; Effective March 31, 2025

If the applicant displays the appropriate characteristics and appears to meet eligibility criteria, the caseworker provides information about potential adult foster care (AFC) homes. The caseworker can arrange visits to appropriate AFC homes or if the applicant is capable or has family and supports available, they may make the arrangements to visit potential AFC homes. In some situations, the caseworker may need to help the applicant make the visit(s).

The visits to potential AFC homes lets the applicant assess the home and lets the AFC provider assess if the applicant will be appropriate in the foster home. The caseworker may contact the provider and share information about the applicant, including the applicant's particular needs and problems. This ensures that the potential provider is fully aware of the responsibilities involved in caring for the applicant and to prevent a potential mismatch of the applicant and provider.

4134 Placement on the Interest List

Revision 25-2; Effective March 31, 2025

If an intake is received for adult foster care (AFC) but no foster homes are available to provide care, place the person's name on the interest list. Determine if other services may be appropriate to meet the person's needs while waiting for placement in AFC. Refer to 2232, The Community Services Interest List System (CSIL), for interest list procedures. The application process for AFC begins when the person's name is released from the interest list.

4135 Adult Protective Services People in Adult Foster Care

Revision 25-2; Effective March 31, 2025

4135.1 Placement of Adult Protective Services People in Adult Foster Care

Revision 25-2; Effective March 31, 2025

In some areas, Adult Protective Services (APS) may use adult foster care (AFC) as a resource for placement of APS people. Approval by the contract manager is required before an APS person moves into a Texas Health and Human Services Commission enrolled AFC household. The purpose of the approval is to determine the:

• appropriateness of the person's characteristics;
• capacity of the foster home to meet the person's needs; and
• compatibility of service delivery to the APS person and the delivery of services to the certified AFC people.

If it is determined by the contract manager that placement in foster care is inappropriate, the APS worker and the provider help the person make other living arrangements.

4135.2 Adult Protective Services Investigations of Adult Foster Care Providers

Revision 25-2; Effective March 31, 2025

Any time Texas Health and Human Services Commission (HHSC) staff suspect abuse, neglect or exploitation of an adult foster care (AFC) person in a foster home, a report must be made immediately to Adult Protective Services (APS).

If reports are made to APS from outside sources, HHSC staff may not be notified of individual allegations against a service provider until after those allegations have been validated. However, APS staff may ask Community Care Services Eligibility (CCSE) staff to help with the delivery of services during their investigation if the alleged mistreatment poses an immediate threat to the safety of AFC residents.

The contract manager assigned to the facility handles disenrollment and corrective actions against the foster home, as appropriate. If the caseworker cannot find a suitable residence for the person, the person is referred to APS for assistance in moving from the foster home.

A person who has the capacity to consent may decide not to move from the foster home, even though the allegation has been validated and the situation is likely to recur. In such an instance, the person's AFC services will be denied and payments to the home will terminate. However, the person may continue to live in the home by making private pay arrangements with the provider.

If a person who does not appear to have the capacity to consent refuses to move from a home operated by a person identified as the perpetrator in a case of validated abuse, neglect or exploitation, make a referral to APS.

4136 Private Pay People and Retroactive Payment Procedures

Revision 25-2; Effective March 31, 2025

4136.1 Private Pay People in Adult Foster Care

Revision 25-2; Effective March 31, 2025

Some adult foster care (AFC) providers may wish to take private pay people. Approval by the contract manager is required before the private pay person is accepted in the home. The AFC provider must contact the contract manager when considering admitting a private pay person. The contract manager will furnish Form 2330, Assessment and Service Plan Approval for Adult Foster Care, to the AFC provider. The AFC provider must complete Form 2330 and return it to the contract manager to approve or disapprove the private pay person. The purpose of the approval is to determine the:

• appropriateness of the person's characteristics;
• capacity of the foster home to meet the person's needs; and
• compatibility of service delivery to the private pay person and the delivery of services to the certified AFC person.

If it is determined by the contract manager that placement in foster care is inappropriate, the AFC provider cannot accept the person.

Refer any issues about placements to the contract manager to resolve.

4136.2 Retroactive Payment Procedures

Revision 25-2; Effective March 31, 2025

If a private pay applicant already in the foster home applies for adult foster care (AFC) and meets all eligibility requirements, AFC can be approved retroactive to the date of intake.

AFC may be authorized retroactively with supervisory approval to the latter of the date of:

• request for services intake date; or
• entry into the foster home.

Supervisory approval is required in all situations. If an applicant does not meet eligibility requirements including appropriate characteristics, then AFC is not authorized. It is the person's responsibility to arrange for payment to the foster home or relocate.

4140 Adult Foster Care Case Worker Procedures

Revision 17-1; Effective March 15, 2017

4141 Eligibility Determination

Revision 25-2; Effective March 31, 2025

To determine eligibility for adult foster care (AFC), the caseworker must:

• certify that the applicant meets financial and functional eligibility on Form 2064, Eligibility Worksheet;
• determine that the applicant has an agreement with an enrolled AFC home to potentially move into the home; and
• document on Form 2330, Assessment and Service Plan Approval for Adult Foster Care, that the applicant meets the appropriate criteria for AFC.

After eligibility is determined, the caseworker submits the person's case record to their supervisor for review and approval. Documentation in the case record must be complete to enable the supervisor to certify the person's need for care and the appropriateness or inappropriateness of the placement arrangement.

4142 Supervisory Approval

Revision 25-2; Effective March 31, 2025

Upon receipt of the case record, the supervisor reviews:

• Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, to verify the person's functional need for care;
• Form 2330, Assessment and Service Plan Approval for Adult Foster Care, to verify the appropriateness of the applicant; and
• any other documentation, including the case narrative to review the person's care needs.

The supervisor may consult with the contract manager to evaluate the capacity of the foster care provider to meet the unique needs of the person in the foster home setting.

The supervisor decides if the foster home can meet the needs of the person and if the person is appropriate for adult foster care (AFC). If so, the supervisor approves AFC and the service plan by signing and dating Form 2330 or by giving verbal approval, which is documented by the caseworker. If the service is not approved, the supervisor confers with the caseworker about problems with the plan, as perceived through the record reviews. The caseworker must find a more suitable arrangement or resolve the potential problems with the person and the foster care provider to their supervisor's satisfaction. Refer the person to Adult Protective Services (APS) if there is reason to suspect abuse, neglect or exploitation.

4143 Service Planning

Revision 25-2; Effective March 31, 2025

Upon approval for adult foster care (AFC), the supervisor and caseworker discuss if the person has any special needs that require more monitoring in the foster home setting beyond the scheduled monitoring. If needed, a monitoring schedule is developed and documented in the case record.

The final care and monitoring plan for the person should address their functional, medical, social and emotional needs and how they might be met in the selected foster care home. Assess if other resources in the community should be used to meet specialized needs of the person. Use of those resources should be documented in the care plan.

If there are health concerns about the person, the regional nurse may be consulted. The nurse may make a recommendation for the person to have a physical or medical exam before moving into the AFC home.

Once the supervisor has approved the person and potential placement in AFC, the caseworker contacts the person and the AFC provider to arrange for the initial visit and a negotiated move-in date for the person.

4150 Finalizing the Care Plan – Required Initial Home Visit

Revision 25-2; Effective March 31, 2025

Program Standard: On or before the date the person moves into the adult foster care (AFC) home, a meeting with the person and the AFC provider is required to discuss the person's care plan and to complete Form 2327, Individual/Member and Provider Agreement.

The person's family members or responsible person may be included in the meeting. The meeting should preferably take place in the AFC home.

During the initial home visit, discuss the person's needs and care plan as indicated on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, and Form 2330, Assessment and Service Plan Approval for Adult Foster Care. Reach an agreement about how to meet person's needs through daily care and activities.

Discuss the person's care plan with the person and family members or responsible party and reach an understanding with them about how the foster care provider will meet their needs. This discussion should ensure that the person, their family or responsible party and the foster care provider are adequately prepared for a new person in the home and that adjustments occur smoothly. Document the care plan and any special needs of the person or special agreements between the person and provider on Form 2327.

4151 Person and Provider Agreement

Revision 25-2; Effective March 31, 2025

Document the service arrangements and the room and board payment agreement on Form 2327, Individual/Member and Provider Agreement, when meeting with the applicant and the adult foster care provider.

Review all the information on the agreement with the applicant, family or responsible person, and the provider. Cover all conditions of the agreement and the following topics in the discussion:

• a full description of the care needs of the applicant, the services and the schedule of care, including if the applicant requires 24-hour supervision by the AFC provider;
• the beginning and end date of the agreement;
• a detailed description of the rights and responsibilities of the applicant and the provider;
• an explanation of the applicant's right to privacy and confidentiality;
• the monthly room and board amount the applicant agrees to pay the provider;
• an inventory of the applicant’s personal effects;
• the names, addresses and phone numbers of people to notify in an emergency, including the applicant's physician, family members or responsible person;
• any special habits and needs of the applicant and any special arrangements or agreements between the applicant and the provider;
• any other training needs of the provider and methods to get that training;
• the responsibility of both the applicant and the provider to notify CCSE staff and the contract manager of problems, such as illnesses, hospitalizations, acts of violence, accidents, complaints about abuse, neglect or exploitation; and
• other conditions that reflect changes in the applicant's condition and might affect the appropriateness of the foster home.

Discuss with the foster care provider the likelihood of problems arising after the applicant moves into the home, notification procedures and suitable actions to take to resolve problems. Also, discuss with the provider the impact of a new applicant on members of the foster care family and other people in the home. Anticipate problems that might arise and how to handle them. Outline the schedule of planned monitoring visits. The applicant and the provider must sign Form 2327 after discussing and agreeing to all the above topics.

4152 Personal Needs and Medical Expenses Allowance

Revision 25-4; Effective Sept. 1, 2025

Adult foster care people must be allowed to keep funds for personal needs and medical expenses.

• People with Medicaid coverage must be allowed to keep at least $50 a month for personal needs.
• People without Medicaid coverage must be allowed to keep at least $85 a month for personal needs and medical expenses.
• All people must be allowed to keep at least one-half of any cost-of-living adjustment received on or after Jan. 1, 1993.

Make sure the person keeps sufficient funds each month for personal needs and medical expenses. The $50 and $85 amounts are minimum amounts. The person may need to keep more depending on their circumstances. Help the person decide how much they spend on prescription drugs and medical bills each month. When the room and board agreement is negotiated, also consider personal expenses such as replacement of clothing and toiletries.

Related Policy

26 Texas Administrative Code Section 271.161 

4153 Room and Board Agreement

Revision 25-2; Effective March 31, 2025

Ensure that the person and provider understand that the room and board arrangement with the provider is separate from the Texas Health and Human Services Commission (HHSC) payment for services. The person pays the provider for room and board. Help the provider and the person negotiate the room and board agreement. The amount paid may be influenced by prevailing rates in the community. The room and board agreement and any other monetary arrangements are entered on Form 2327, Individual/Member and Provider Agreement.

If the person is moving into the adult foster care home mid-month, prorate the amount of room and board for the month and advise the person and provider of the prorated amount. The ongoing amount of room and board is negotiated with the person and provider and both amounts are recorded on Form 2327.

4153.1 Changes in the Room and Board Agreement

Revision 25-2; Effective March 31, 2025

If the person has a change in income or expenses, they or the provider may request a change in the amount of room and board payment. Changes in the room and board payment are negotiated between the person and the provider. They are documented on Form 2327-A, Room and Board Amendment to the Individual/Member and Provider Agreement.

4154 Leave Away from the Foster Home and Charges

Revision 25-2; Effective March 31, 2025

Texas Health and Human Service Commission pays the daily rate for up to 14 days of leave for each 12-consecutive-month period when an authorized person is away from the foster home. Payment for leave over 14 days per year is the person’s responsibility. Any charges are between the person and provider because they have negotiated a monthly room and board agreement. However, charges may not exceed the daily room and board rate.

The adult foster care provider is responsible for notifying the caseworker by the next workday when a person is away from the foster home for personal leave or hospitalization.

During the initial home visit, the caseworker reviews the information about the person’s responsibility to pay a bed hold charge when away from the home. Ensure the person understands that if they use more than 14 days of leave during a 12-month period, they are responsible for paying the provider the full daily rate.

Related Policy

26 Texas Administrative Code Section 271.157(f)
26 Texas Administrative Code Section 271.157(g)

4155 Authorization of Adult Foster Care

Revision 25-2; Effective March 31, 2025

After all procedures are completed, the caseworker sends the person Form 2065-A, Notification of Community Care Services. The caseworker authorizes adult foster care on Form 2101, Authorization for Community Care Services, in the Service Authorization System wizards and sends the provider a copy of Form 2101.

4156 Adult Foster Care and Day Activity and Health Services

Revision 26-1; Effective June 1, 2026

Some services cannot be authorized at the same time as AFC. Refer to the chart in Appendix XX, Mutually Exclusive Services. Day Activity and Health Services (DAHS) may be authorized for AFC people under the following conditions. The AFC person:

• requests to attend DAHS for socialization; or
• has a medical need that cannot be met by the AFC provider.

Documentation in the case record must clearly specify that at least one of the above conditions is met. Review 4222 Medical Eligibility Criteria, for the DAHS eligibility requirements for a medical need.

DAHS may be authorized for the maximum of 10 units per week. However, the authorization must be related to the person's need and not authorized for the convenience of the AFC provider.

Per 26 Texas Administrative Code Section 278.113(a), Provider Responsibilities, the adult foster care provider must:

• provide services to residents per the person’s service plan and the resident and provider agreement;
• meet all requirements and conditions stated on the resident and provider agreement, approval of foster care and person’s service plan;
• ensure that an approved substitute provider is present in the home if at least one resident remains when the provider plans to be absent from the home for more than three hours in a 24-hour period. Residents whose care plans specify the need for 24-hour supervision may not be left without the supervision of an approved substitute provider for any period.

If a person is authorized to attend DAHS but is ill or prefers not to attend on a particular day, the AFC provider must provide supervision in the AFC home for the person.

4160 Monitoring

Revision 25-2; Effective March 31, 2025

Program Standard: Monitoring contacts are required monthly for the first three months the person is in the foster home. Two of the monitoring contacts may be made by phone if appropriate for the person. At least one of the contacts must be a home visit to the person in the foster home and the person must be interviewed privately.

4161 30-Day, 60-Day and 90-Day Monitoring Contacts

Revision 25-2; Effective March 31, 2025

Monthly monitoring contacts must be completed during the first three months after the person is certified for adult foster care. Two of the monitoring contacts may be made by phone. At least one of the three monitoring contacts must be made face to face with the person in the foster home. The person must be seen alone so any problems with the provider or the home can be freely discussed. Help resolve any problems noted. Contact the contract manager if there are problems with the home or the provider.

4162 Six-Month Monitoring Contact

Revision 25-2; Effective March 31, 2025

After the first three months, the person must be monitored at regularly scheduled six-month intervals, unless the caseworker and supervisor have determined that the person requires more frequent monitoring. The first six-month monitoring contact occurs three months after the 90-day monitoring contact.

Regular monitoring visits should assess the person's needs and if the provider is addressing and meeting those needs. Report to the contract manager if the adult foster care provider is not addressing or meeting those needs. Carefully monitor the person's physical and medical condition to determine if initial problems are resolved and if new problems are arising due to decreased functional capacity or illness. Use regional nurses in this assessment and monitor process as needed.

All monitoring contacts must be recorded on Form 2314, Satisfaction and Service Monitoring, in the Service Authorization System monitoring wizard.

4170 Significant Changes

Revision 25-2; Effective March 31, 2025

It is the responsibility of the caseworker and the adult foster care (AFC) provider to ensure that the AFC person is in an appropriate setting to meet their needs. When the AFC person has a change in functional need, health problems or changes in behavior, it is the responsibility of the AFC provider to notify the caseworker.

Within 14 calendar days or sooner, as appropriate, the caseworker must follow-up with the person and provider to determine if changes to the care arrangement are needed. The caseworker may consult with the supervisor to determine how quickly a response is needed to the situation.

Give particular attention to people who reflect dramatic changes in functional need, medical problems or behaviors that are inappropriate for foster care. Alert family members, the responsible party or guardian to the situation. Discuss with them and the person the potential for the person to remain in the foster home. If a person has a guardian appointed by the courts, the guardian acts on the person's behalf. If the person has had a decline in their medical condition or functional ability, consult the regional nurse and request that the nurse make a visit to the person for a medical assessment.

4171 Changes in the Service Plan

Revision 25-2; Effective March 31, 2025

Document the changes in a person's condition on Form 2060, Needs Assessment Questionnaire and Task or Hour Guide, and Form 2330, Assessment and Service Plan Approval for Adult Foster Care, noting changes in the person's functional ability and appropriateness for adult foster care (AFC) placement. Discuss the changes with the supervisor, regional nurse if needed, AFC provider and family members. Refer to 2550, Identifying People at Risk, if the person’s health and safety are at risk and more service planning is needed. If AFC continues to be appropriate for the person, document the needed changes in the service plan on Form 2327, Individual/Member and Provider Agreement.

4172 Adult Foster Care No Longer Appropriate

Revision 25-2; Effective March 31, 2025

If after a review of Form 2060, Needs Assessment Questionnaire and Task or Hour Guide, and Form 2330, Assessment and Service Plan Approval for Adult Foster Care, the person's needs can no longer be met or the person is no longer appropriate for adult foster care, discuss alternative living arrangements with the person, family or responsible party. Long-range care plans should be discussed plainly with the person, family members and the foster care provider to ensure that all are aware of the capabilities and limitations of adult foster care services for people with deteriorating medical or functional conditions. People who become inappropriate for foster care must be advised of other available options. Help people and their family members in this decision process and with transfer activities when necessary. If the provider decides that the person is not appropriate for care in their home, the provider contacts the caseworker to request that the person be transferred to another placement. The caseworker is responsible for preparing the person for the move and transition.

4173 Termination of Adult Foster Care Services

Revision 25-2; Effective March 31, 2025

Once a person is identified as inappropriate for foster care, the caseworker must negotiate a time frame with the person, family or responsible party and the adult foster care (AFC) provider for the person to move. The time frame is determined on a case-by-case basis depending on the urgency and severity of the situation and how quickly an appropriate placement can be arranged. If the person has been a threat to the health and safety of other people or has displayed inappropriate behaviors so that the provider is asking the person to move immediately, then the caseworker must make every effort to locate another living arrangement as soon as possible. If other living arrangements are not readily available for the person, refer to Adult Protective Services (APS) to help locate appropriate placement for the person.

If the person will not be transferring to another AFC setting, send the person Form 2065-A, Notification of Community Care Services, with the negotiated move date as the end date of services. Unless the person's service is being terminated due to threat to health and safety, review 2811, Effective Dates. Give the person at least 12-calendar days' notice. Terminate AFC services on Form 2101, Authorization for Community Care Services.

If there is resistance to the move from the person, family or the provider, additional staffing with the person, family, responsible party and provider may be required to resolve the problem. Request that the supervisor and contract manager attend the staffing, if necessary. Advise the person and provider that AFC services will terminate on the date specified on Form 2065-A. The provider has the right to begin eviction proceedings as specified in the provider's resident rights and responsibilities. Ensure that the person and responsible party understand the consequences of eviction. If the provider must use eviction procedures and the person has refused to make other living arrangements, refer the person to APS.

If the person and provider decide that the person will remain in the home as a private pay person, then the contract manager must give approval. Make sure the person and provider understand that there are no case management services or payment arrangements from the Texas Health and Human Services Commission for a private pay person.

4180 Annual Reassessment

Revision 25-2; Effective March 31, 2025

Reassess the adult foster care (AFC) person every 12 months as outlined in 2660, Reassessments and Recertification Procedures. Form 2330, Assessment and Service Plan Approval for Adult Foster Care, must be completed annually and signed by the supervisor. Carefully review the appropriate and inappropriate characteristics on Form 2330. Be alert for changes that indicate the person is no longer appropriate for AFC or that their medical or functional needs can no longer be met. If the person's condition is deteriorating, but not to the point that AFC is currently inappropriate, discuss with the person that a move may be necessary in the future.

Reevaluate the service plan at each reassessment and update per the person's new or changed needs. Discuss changes in the person's need level and in the service plan with the foster care provider and get supervisory approval.

Reauthorize AFC on Form 2101, Authorization for Community Care Services.

4210 Description

Revision 22-3; Effective Sept. 1, 2022

Day Activity and Health Services (DAHS) include nursing and personal care services, physical rehabilitative services, nutrition services, transportation services and other supportive services. These services are provided at facilities licensed and certified by the Texas Health and Human Services Commission(HHSC). Except for holidays, these facilities must have services available at least 10 hours a day, Monday through Friday.

The method of payment is a unit of authorized service and is defined as half a day. One unit of service constitutes three hours but less than six hours of covered services provided by the DAHS facility. Six hours or more of service constitutes two units of service. Time spent in approved transportation provided by the DAHS facility shall be counted in the unit of service.

Services must be provided according to the recipient's service plan. Discuss with the recipient, their family or authorized representative regarding the recipient’s condition, program plan and staff administering the plan.

Recipients must be given the opportunity to receive medical attention and help in getting health services not available from the provider.

The facility must be used only for authorized purposes.

Related Policy  

Day Activity and Health Services Provider Manual

4211 Nursing and Personal Care

Revision 25-2; Effective March 31, 2025

Services include:

• evaluating and observing a person's status and instituting appropriate nursing intervention, when needed, to stabilize their condition or prevent complications;
• helping the person order, maintain, or administer prescribed medication;
• promoting and participating in the person's education and counseling;
  • Participation is based on their health needs and illness status; and
  • involving the person and other people for a better understanding and implementation of immediate and long-term health goals;
• helping with personal care tasks, including the restoration or maintenance of the person's ability to perform personal care skills; and
• assessing and evaluating the person's health status.

4212 Physical Rehabilitation

Revision 25-2; Effective March 31, 2025

Services include:

• restorative nursing, including the use of nursing knowledge and skills to help the person achieve their maximum degree of functioning;
• group and individual exercises, including range-of-motion exercises; and
• transportation to and from a facility approved to provide therapies, if specialized services are needed on the days the person attends the Day Activity and Health Services (DAHS) facility.

4213 Nutrition

Revision 25-2; Effective March 31, 2025

Services include:

• one hot meal, served between 11 a.m. and 1 p.m. that should supply one-third of the recommended daily allowance (RDA) for adults as recommended by the U.S. Department of Agriculture;
• special diets required by the person's plan of care;
• supplementary mid-morning and mid-afternoon snacks; and
• dietary counseling and nutrition education for the person and family.

4214 Transportation

Revision 17-1; Effective March 15, 2017

If needed, the Day Activity and Health Services (DAHS) facility ensures transportation to and from the facility.

4215 Other Supportive Services

Revision 25-2; Effective March 31, 2025

Services include:

• social activities, on-site or in the community; and
• recreational therapy in a program planned to meet the person's social needs and interests.

4220 Eligibility

Revision 23-1; Effective March 1, 2023

The provision of Community Care Services Eligibility (CCSE) services is not allowed for people who live in an institutional setting. An institutional setting is defined as a skilled nursing facility or an intermediate care facility, including an intermediate care facility for persons who have an intellectual disability.

One unit of DAHS is at least three hours but less than six hours per week. A person who needs less than one unit (three hours) of service per week is not eligible. DAHS cannot be authorized for more than 10 units per week.

To be eligible for DAHS, an applicant or recipient must have:

• Medicaid or be income and resource eligible;
• an unmet need for DAHS;
• a chronic medical diagnosis and physician’s orders for DAHS; and
• one or more functional limitations and the potential for receiving therapeutic benefits from DAHS.

Related Policy 

Resource Limits, 3210
Income and Income Eligibles, 3310

4221 Financial Eligibility Criteria

Revision 17-1; Effective March 15, 2017

Medicaid recipients are financially eligible for Title XIX Day Activity and Health Services (DAHS). Applicants who are not Medicaid recipients but who are categorically eligible or within the Community Care Services Eligibility (CCSE) income and resource limits are financially eligible for Title XX DAHS. Applicants are not eligible if they are receiving another CCSE service that duplicates DAHS. See 3000, Eligibility for Services, for the policies concerning income and resources.

4222 Medical Eligibility Criteria

Revision 26-2; Effective June 1, 2026

A person must have the following to meet the medical eligibility criteria for DAHS:

• An identified chronic medical condition and physician's orders that certify the applicant has a need for DAHS.
• One or more function limitation(s) and the potential to benefit therapeutically from DAHS, as determined by a health assessment of the applicant’s medical needs. The health assessment will identify the functional need or needs and the therapeutic benefit the applicant will receive from personal care, habilitative or restorative activities by participation in DAHS.

The provider agency completes Form 3055, Physician’s Orders (DAHS), and Form 3050, DAHS Health Assessment/Individual Service Plan:

• for new enrollments,
• for transfers to a different DAHS provider agency, and
• if the recipient’s condition changes.

If a DAHS case is terminated using Form 2101, Authorization for Community Care Services, a new Form 3055 must be obtained. 

Note: A physician cannot be reimbursed for completing Form 3055 if they received Medicaid reimbursement for the diagnosis and treatment of the person's illness that makes them eligible for DAHS.

Related Policy 

Service Plan Changes Reported by the Facility, 4261
DAHS Transfers, 4262
Facility Response for Facility-Initiated Referrals, 4234
Facility Response to CCSE Staff Referrals, 4235

4223 Unmet Need Criteria

Revision 17-1; Effective March 15, 2017

Applicants must have an unmet need for services and are not eligible for Day Activity and Health Services (DAHS) if they are receiving another CCSE service that duplicates DAHS. DAHS may be received with some other services as long as there is not a duplication of services.

4223.1 DAHS in Conjunction with Other Services

Revision 25-2; Effective March 31, 2025

Day Activity and Health Services (DAHS) may be received along with some other services, including the following:

• People who receive personal care and supervision through Adult Foster Care (AFC) services may receive 10 units per week of DAHS to benefit medically from the other services provided by the DAHS program. Medical need must be documented. Review 4156, Adult Foster Care and Day Activity and Health Services, for more information.
• A Consumer Managed Personal Attendant Services (CMPAS) person may receive up to 10 units of DAHS per week.
• Residential Care (RC) people may receive DAHS only if the services provided by the DAHS facility are medical services that cannot be provided by the RC facility. An RC person may receive no more than one unit per day of DAHS, which is the time needed for the DAHS facility to provide medical services.
• A person in the following waiver programs can access DAHS if the person meets the DAHS eligibility criteria:
  • Home and Community-based Services (HCS), if 18 or older;
  • Community Living Assistance and Support Services (CLASS), if 18 or older;
  • Deaf Blind with Multiple Disabilities (DBMD); and
  • Texas Home Living (TxHmL).

Review Appendix XX, Mutually Exclusive Services, for complete information about which Long-term Services and Supports may be received in conjunction with others. Staff must also ensure that people with active Medicaid coverage are not certified for Title XX DAHS.

4224 DAHS Licensure Age Requirements

Revision 25-2; Effective March 31, 2025

Day Activity and Health Services (DAHS) facilities licensed as adult day care centers cannot serve people under 18. A person under 18 requesting DAHS must be advised that even if eligibility criteria for DAHS are met, they may not be able to access the service unless a facility is licensed to serve children and has a separate facility not accessible to adults. The caseworker should refer the applicant to alternative services, such as:

• after school or summer programs offered by independent school districts;
• Texas Workforce Commission providers that offer day care services;
• local day care centers;
• faith-based local organizations; or
• other organizations that assist children with specific physical or medical conditions.

4230 DAHS Approval

Revision 24-4; Effective Sept. 1, 2024

Determination and redetermination of eligibility for Day Activity and Health Services (DAHS) involves the cooperative efforts of the regional nurse, the caseworker, the facility nurse and the person's physician.

4231 Intake

Revision 25-2; Effective March 31, 2025

Intake into Day Activity and Health Services (DAHS) begins when the caseworker receives a request for services. Requests for DAHS services may be made by:

• the person;
• their physician;
• their authorized representative; or
• an interested party.

A DAHS facility may also request services for a person who is already attending the DAHS facility if the applicant is:

• Medicaid eligible; and
• not a DAHS person.

4231.1 Facility-Initiated Referrals

Revision 22-3; Effective Sept. 1, 2022

Facility-initiated referrals only apply to Title XIX DAHS services. Only Medicaid eligible applicants are eligible for facility-initiated referrals. The facility may admit and begin services for a Medicaid recipient before receiving approval from HHSC if it is willing to risk the loss of revenue if the applicant is determined ineligible. The applicant cannot be currently receiving DAHS at any other facility that has a DAHS contract. 

Applicants have freedom of choice in the selection of qualified providers. CCSE staff and the regional nurse must coordinate transfers from one DAHS facility to another to prevent duplication of services or gaps in coverage.

For the facility-initiated referral, the facility must:

• have obtained verbal or written physician orders;
• verbally notify CCSE staff or the intake unit and request DAHS services for the applicant; and
• follow up the verbal notification in writing within seven calendar days by sending Form 2067, Case Information, to CCSE staff.

The date of the verbal notification is the date of request for DAHS.

4231.2 Intake Response

Revision 25-2; Effective March 31, 2025

Within 14 calendar days of receipt of the intake, the caseworker must contact the applicant either by phone or face-to-face contact to complete the application for Day Activity and Health Services (DAHS). Time frames for responding to other requests for services  are based on the priority of the intake. Refer to 2320, Caseworker Response, for priorities and time frames. A home visit is required only at the applicant's request.

Before the contact, the caseworker checks the Texas Integrated Eligibility Redesign System (TIERS) to determine if the applicant is Medicaid eligible or categorically eligible. The caseworker also checks the Service Authorization System Online (SASO) to determine the applicant is not a current DAHS recipient.

If the applicant is not Medicaid eligible, determine if the applicant will meet the criteria for Title XX Services and if Title XX Services are available. Review 2230, Interest List Procedures.

If the applicant is not Medicaid eligible and the intake is a facility-initiated referral, notify the facility by phone and follow up with Form 2067, Case Information, letting the facility know the applicant is not Medicaid eligible and is not eligible for the facility-initiated referral.

If the applicant is already a DAHS recipient at another facility, notify the facility by phone and follow up with Form 2067, letting the facility know the applicant is already a recipient, is not eligible for the facility-initiated referral and must follow the transfer procedures outlined in 4262, DAHS Transfers.

4231.3 Initial Interview

Revision 24-5; Effective Nov. 1, 2024

The caseworker contacts the applicant by phone or face-to-face to complete the assessment interview. During the interview, the caseworker discusses services available through Day Activity and Health Services (DAHS) and determines if the applicant seems to have a medical diagnosis and a functional disability related to the medical diagnosis, an unmet need for services, or is receiving other services that duplicate DAHS.

During the assessment, the caseworker:

• completes Form 2307, Rights and Responsibilities, and if the contact is by phone, mails Form 2307 to the person;
• completes Form 2059-W, Summary of Individual's Need for Service Worksheet, to be entered into the Service Authorization System;
• assesses the number of units such as one unit equals at least three hours but less than six hours, the applicant prefers and needs per week;
• assesses the applicant for any other needed services; and
• gets an Application for Assistance form review 2333, Applications, if the applicant is not Medicaid or categorically eligible.

The date of assessment is when the 30-day time frame for the caseworker to complete the application process begins.

4231.4 Response to People Who Are No Longer Attending DAHS

Revision 25-2; Effective March 31, 2025

If the applicant has stopped attending Day Activity and Health Services (DAHS) before the application process is complete, the applicant does not have to complete an application or Form 2307, Rights and Responsibilities, if they were Medicaid-eligible when DAHS was received. Attempt to contact the person by phone, mail or home visit to:

• determine if they are receiving DAHS at another facility or receiving other Community Care Services Eligibility (CCSE) services that may duplicate DAHS;
• verify their attendance at the facility; and
• complete Form 2059-W, Summary of Individual's Need for Service Worksheet, to be entered into the Service Authorization System Online (SASO).

If unable to locate the person or if the person refuses to provide any information, verify through automation records the person's effective date of Medicaid coverage and if the person is receiving other CCSE services that may duplicate DAHS. Review 2433, Determining Unmet Need in the Service Arrangement Column, to determine CCSE services that duplicate each other. Complete and send to the facility:

• Form 2101, Authorization for Community Care Services, if the person is eligible; or
• Form 2065-A, Notification of Community Care Services, if the person is ineligible.

Send Form 2065-A to the applicant.

Review 4233, Initial Eligibility Determination and Referral.

Note: Coordinate with the local Area Agency on Aging to ensure there is no service duplication.

4232 Freedom of Choice

Revision 25-2; Effective March 31, 2025

When referring a person to a Day Activity and Health Services (DAHS) facility, describe the facility to the person and the type of service available. If possible, the person should visit the facility before services begin. Based on federal requirements for services funded under Medicaid, the person maintains freedom of choice among the DAHS facilities that serve their area. If the person meets all DAHS eligibility requirements, they have freedom of choice to choose a DAHS facility, regardless of any relationship to the provider.

A DAHS facility must serve eligible people unless a facility is at licensed capacity.

Refer people to DAHS facilities based on the following priorities:

• person's choice;
• physician's choice, if stated;
• rotation of eligible providers.

After the person has selected a facility, contact the facility to determine if there are openings. If the facility is operating at capacity, contact the person and arrange another satisfactory placement.

DAHS facility staff maintain an interest list for Title XIX and private-pay people. Medicaid regulations prohibit HHSC from maintaining an interest list for any Title XIX service.

HHSC regional staff maintain the interest list for Title XX applicants.

Related Policy

Interest List Procedures, 2230

4233 Initial Eligibility Determination and Referral

Revision 25-2; Effective March 31, 2025

Title XX DAHS

After the initial assessment, determine the following:

• the applicant meets the financial eligibility criteria;
• the applicant has an unmet need for Day Activity and Health Services (DAHS); and
• there is no duplication of other services.

Community Care Services Eligibility (CCSE) staff complete the referral Form 2101, Authorization for Community Care Services; and send the referral packet to the DAHS facility within five business days.

The referral packet must include:

• a cover sheet;
• the Long-term Care Services Intake System (NTK) generated Form 2110, Community Care Intake; and
• a copy of the following Service Authorization System Online  (SASO) generated forms:
  • Form 2059, Summary of Client's Need for Service;
  • Provider Referral Supplement; and
  • Form 2101.

If it is determined the applicant is not eligible for DAHS, send Form 2065-A, Notification of Community Care Services, to the applicant.

Title XIX DAHS

Title XIX DAHS referrals are initiated by the facility after an applicant begins attending the DAHS facility. When completing the referral packet, indicate in the comments section of Form 2101 that the applicant is being referred for facility-initiated DAHS. If the applicant no longer attends the DAHS facility, enter the date the applicant stopped as the end date on Form 2101 and note in the comments section the applicant is no longer attending DAHS.

If it is determined the applicant is not eligible for facility-initiated DAHS:

• send Form 2065-A to the applicant;
• send a copy of Form 2065-A to the DAHS facility; and
• notify the facility by phone of the denial.

If the applicant qualifies for Title XX DAHS, send the referral packet and notify the facility the applicant is eligible for Title XX DAHS instead of facility-initiated DAHS.

Related Policy

Content of Referral Packets, Appendix XIII

4234 Facility Response for Facility-Initiated Referrals

Revision 25-2; Effective March 31, 2025

The Day Activity and Health Services (DAHS) facility must submit a full prior approval packet to the HHSC regional nurse within 30 calendar days for facility-initiated referrals. This is done after the date of the initial physician's orders verbal or written by submitting:

• Form 3050, DAHS Health Assessment/Individual Service Plan; and
• Form 3055, Physician's Orders (DAHS).

4234.1 Regional Nurse Responsibilities for Facility-Initiated Referrals

Revision 24-5; Effective Nov. 1, 2024

The Day Activity and Health Services (DAHS) facility must request written prior approval for all applicants. They make the request from the regional nurse within 30 calendar days after the date of the physician’s orders.

The regional nurse authorizes services and sends Form 2101, Authorization for Community Care Services, to the facility and CCSE staff within five business days if:

• the DAHS facility submits the prior approval packet to the regional nurse within 30 calendar days of the initial physician's orders; and
• the applicant meets all eligibility requirements.

The effective date is the date of the physician's orders on Form 3055, Physician's Orders (DAHS).

Example: The facility receives Form 3055 on April 5 with a physician's signature date of April 1. The facility gets Form 2101 and the referral packet from CCSE staff on April 20. The facility submits the prior approval packet to the regional nurse on April 22, and the nurse receives the packet on April 24. This is within 30 calendar days of the physician's orders, and the applicant meets all eligibility requirements, so the regional nurse authorizes services effective April 1.

If the DAHS facility fails to submit the prior approval packet or additional documentation within the required time frame, the additional documentation is not adequate, or CCSE staff determine the applicant ineligible, the regional nurse cancels the DAHS facility-initiated prior approval, and the DAHS facility is not reimbursed for services. If the applicant meets all eligibility requirements, the regional nurse authorizes services by sending Form 2101 to the facility and CCSE staff.

The nurse may send Form 2101 to CCSE staff by secure email as determined by regional procedures. If the region elects to have the regional nurse notify CCSE staff by email, the nurse must include the applicant's name, identification number and date of authorization in the email. The unit supervisor or other appointed HHSC staff also receives the notice. CCSE staff must go into the Service Authorization System Online (SASO) and print a copy of the authorization Form 2101 and a copy of the email for the case record.

The effective date is the earliest of the following dates on the prior approval packet:

• postage meter date if not canceled by the U.S. Postal Service;
• U.S. Postal Service date; or
• HHSC stamp-in date.

The facility is not reimbursed for any services delivered before the authorization date.

Example:  The facility gets verbal physician's orders and requests services through HHSC on April 1. The facility sends Form 3055 to the physician for completion and signature. CCSE staff complete the assessment and Form 2101 on April 13 and sends the referral packet to the facility. On May 2, the facility receives Form 3055 and mails the prior approval packet to the regional nurse. The regional nurse receives the packet on May 4, which is more than 30 calendar days from the physician's verbal orders. The regional nurse establishes eligibility and authorizes services effective May 2, which is the U.S. Postal Service date on the envelope mailed from the facility.

Critical Omissions for Facility-Initiated Referrals

If there are critical omissions, the regional nurse sends Form 3070, Day Activity and Health Services Notification of Critical Omissions, to the facility within five business days of receipt of the prior approval packet and sends a copy to CCSE staff. The facility must send corrections to the regional nurse within 14 calendar days. If the corrections are received within the time frame and the applicant meets eligibility requirements, the regional nurse authorizes services effective the date of the physician's orders on Form 3055. If the facility fails to meet this time frame, the date of prior approval can be no earlier than the postmark or HHSC-stamped date on the corrected documentation.

Related Policy

Critical Omissions, 4236

4234.2 Caseworker Responsibilities for Facility-Initiated Referrals

Revision 25-2; Effective March 31, 2025

It is the caseworker's responsibility to determine the applicant's eligibility within 30 calendar days from the assessment date and to track if Form 2101, Authorization for Community Care Services has been completed by the Texas Health and Human Services Commission (HHSC) regional nurse. If, on the 30th day the caseworker has not received Form 2101 or received notice of critical omissions, the caseworker contacts the regional nurse to ask if the required information was received. The caseworker must document the contact and the regional nurse's response. The caseworker will take one of the following actions:

• If the regional nurse has received the prior approval packet and services will be authorized, the regional nurse advises the caseworker of the anticipated authorization date and sends Form 2101 to the facility and the caseworker.
• If the regional nurse has sent the prior approval packet back to the facility for critical omissions, the case worker allows another 30 calendar days for the facility to send corrections and receive approval. If Form 2101 has not been received at the end of the 30 calendar days, the caseworker contacts the regional nurse for the status and anticipated dates of approval or denial.
• If the regional nurse has not received the prior approval packet or the critical omissions corrections, the caseworker must deny the application and notify the applicant, the facility and the regional nurse of the denial, using Form 2065-A, Notification of Community Care Services. The facility will not be reimbursed for the services delivered.

The applicant may reapply for services, but new physician's orders and a new assessment must be completed.

4235 Facility Response to CCSE Staff Referrals

Revision 25-2; Effective March 31, 2025

For referrals initiated by CCSE staff, the DAHS facility must respond within 14 calendar days of receipt of the referral Form 2101, Authorization for Community Care Services.

Within 14 calendar days of the receipt of the referral Form 2101, the DAHS facility sends the prior approval packet to the HHSC regional nurse. The prior approval packet contains:

• referral Form 2101;
• Form 3050, DAHS Health Assessment/Individual Service Plan; and
• Form 3055, Physician's Orders (DAHS).

If the DAHS facility notifies CCSE staff that the health assessment or the physician's orders will be delayed beyond 14 calendar days, evaluate the cause of the delay. Consult the recipient to determine if they should be referred to another provider of their choice. If CCSE staff determine a new referral is needed, verbally notify the original provider and the HHSC regional nurse. Send Form 2067, Case Information, to the original provider to confirm the withdrawal.

Related Policy

Initial Eligibility Determination and Referral, 4233

4235.1 Regional Nurse Responsibilities for CCSE Referrals

Revision 21-4; Effective December 1, 2021

When the regional nurse receives the required forms from the facility, the regional nurse reviews Form 2101, Authorization for Community Care Services, Form 3050, DAHS Health Assessment/Individual Service Plan, and Form 3055, Physician's Orders (DAHS), to determine if the applicant meets the Day Activity and Health Services (DAHS) medical eligibility criteria. If there are critical omissions or errors in the required documentation, the regional nurse must follow the critical omissions procedures.

The regional nurse must keep the envelope that the prior approval material is mailed in. If more than one prior approval packet is included in the envelope, the regional nurse or designee must list the name of each applicant that a prior approval packet had in the envelope.

The regional nurse grants approval if the:

• applicant meets the eligibility criteria; and
• there are no critical omissions or errors in the documentation from the facility.

The regional nurse generates and sends the authorization, Form 2101 to the facility and CCSE staff within five business days of receipt of the prior approval request. This provides notification of approval or denial of the applicant. 

The region has the option of allowing the regional nurse to send notification of the authorization to CCSE staff by secure email, rather than sending the paper copy. Each region may determine which method best suits its needs. The regional nurse will continue to send a paper copy to the provider.

If the region elects to have the regional nurse notify CCSE staff by email, the nurse must include the applicant's name, identification number and date of authorization in the email. The unit supervisor or other appointed HHSC staff will also receive the notice. CCSE staff must go into the Service Authorization System Online (SASO) and print a copy of the authorization Form 2101 and a copy of the email for the case record.

Related Policy

Medical Eligibility Criteria, 4222 
Facility Response to Case Worker Referrals, 4235
Critical Omissions, 4236

4235.2 Effective Dates for Initial Cases

Revision 25-2; Effective March 31, 2025

The regional nurse establishes the beginning date of Day Activity and Health Services (DAHS) coverage based on if the person is referred by the caseworker or by the facility as a facility-initiated referral, and if there are critical omissions or errors in the required documentation.

For caseworker referrals, the regional nurse establishes the Begin Date of coverage on Form 2101, Authorization for Community Care Services, as the date it is expected to be mailed to the facility. If this date is not feasible, the regional nurse negotiates the Begin Date of coverage on Form 2101 with the caseworker and the facility, per the person's needs and the person's unique circumstances.

The regional nurse establishes the beginning date of coverage on Form 2101 for a facility-initiated referral using the date of the physician orders. If there are corrections for critical omissions or errors in the required documentation, the regional nurse follows procedures in 4236, Critical Omissions, and establishes the effective date as the:

• date of the physician orders, if corrections are received within 14 calendar days of the date the regional nurse sends Form 3070, Day Activity and Health Services Notification of Critical Omissions; or
• date the corrections are received, if the corrections are not received within 14 calendar days.

4235.3 CCSE Staff Responsibilities for Caseworker Referrals

Revision 25-2; Effective March 31, 2025

CCSE staff sends Form 2065-A, Notification of Community Care Services, to the person notifying the person of eligibility or ineligibility. This is done within two business days of receipt of Form 2101, Authorization for Community Care Services, from the regional nurse.

If the person was a facility-initiated referral, a copy of Form 2065-A is also sent to the facility. The effective date on Form 2065-A must match the effective date on Form 2101 from the regional nurse.

4236 Critical Omissions

Revision 24-5; Effective Nov. 1, 2024

If the required documentation contains errors or omissions, the HHSC regional nurse:

• completes Form 3070, Day Activity and Health Services Notification of Critical Omissions; and
• sends it to the facility along with the rejected prior approval packet.

HHSC must receive corrections of critical omissions or errors in DAHS facility documentation within 14 calendar days after the HHSC regional nurse mails Form 3070, Day Activity and Health Services Notification of Critical Omissions, to the facility.

If the facility fails to submit the required documentation on time, contact the applicant within three business days of being notified by the HHSC regional nurse. Explain that a referral can be made to another DAHS facility due to the delay, if the applicant, their family, or their authorized representative prefers this option.

The regional nurse uses the earliest of the following dates to establish the date that prior approval material and corrections of critical omissions or errors are received from the facility:

• postage meter date if not canceled by the U.S. Postal Service;
• U.S. Postal Service date; or
• HHSC stamp-in date.

If the facility returns the packet before the 14th calendar day but all identified omissions or errors still need to be corrected, the facility has the rest of the 14 calendar days to resubmit additional corrections. The regional nurse verbally notifies the facility that:

• the corrected packet does not address all errors noted on Form 3070; and
• additional corrections must be submitted by the 14th calendar day to avoid a gap in payment.

The regional nurse documents this verbal notification, date and name of the contact in the case record.

4240 Facility Initiation of Services

Revision 25-1; Effective March 1, 2025

The facility must complete and return HHSC’s authorization for community services form to the caseworker within 14 calendar days from the begin date on HHSC’s authorization for community care services form. The Day Activity and Health Services (DAHS) facility must indicate the date services were initiated, the schedule for delivering services, and the total units authorized for the person.

The 14-calendar day period for the facility to return Form 2101, Authorization for Community Care Services, encourages the facility to start services promptly. The 14-calendar day period does not apply if a person is already attending a DAHS facility when the facility refers them to the caseworker for example, a facility-initiated referral. For facility-initiated referrals, the facility returns Form 2101 as soon as possible after receiving it from the caseworker.

4250 Monitoring

Revision 25-2; Effective March 31, 2025

Monitor the services based on the priority assigned to the person's case. For priority levels, review:

• 2540, Priority Status;
• 2710, Monitoring Visits and Contacts;
• 2711, Monitoring Visits for Community Attendant Services (CAS) Individuals; and
• 2712, Six-Month Monitoring Contacts.

Timelines for Day Activity and Health Services (DAHS) only cases are measured differently than other situations because there is no Form 2060, Needs Assessment Questionnaire and Task or Hour Guide, date to count from. Measure DAHS-only timelines from the:

• initial contact date for initial certifications; or
• the previous date on Form 2314, Satisfaction and Service Monitoring, for recertifications.

The regional nurse also monitors DAHS through utilization review.

4260 Changes

Revision 25-2; Effective March 31, 2025

The Day Activity and Health Services (DAHS) facility must inform the caseworker of changes in the person's status, condition and when the person is suspended from attending DAHS.

4261 Service Plan Changes Reported by the Facility

Revision 25-2; Effective March 31, 2025

The DAHS facility must verbally notify CCSE staff of any changes in the recipient’s status or condition. This may require a change in their plan of care, units of service or service termination. If so, they must follow up with written notification within seven calendar days.

CCSE staff approve changes in the plan of care which may affect eligibility or units of service.

Within 14 calendar days of receipt of Form 2067, Case Information:

• review the request for a change which may affect eligibility or units of service;
• contact the recipient to confirm they agree with the proposed change; and
• respond to the written request.

If CCSE staff and the recipient agree with the facility's request, complete and send Form 2101, Authorization for Community Care Services. If CCSE staff and the recipient agree to terminate or reduce services, follow adverse action procedures.

If CCSE staff or the recipient disagree with the request, send Form 2067 to the facility to explain the reason for not making the change.

Related Policy

Individual Notification Procedures, 2810
Effective Dates, 2811
Form 2101 Coverage Dates for Title XIX Services, Appendix XXIII

4261.1 Person’s Absences

Revision 25-2; Effective March 31, 2025

If a Day Activity and Health Services (DAHS) participant is absent from the facility for 15 consecutive days, the DAHS facility must verbally notify the Texas Health and Human Services Commission (HHSC) of the suspension by the first business day after services are suspended. They then send Form 2067, Case Information, within seven business after the incident was reported verbally.

If a person is absent from a regularly scheduled program, the DAHS facility must contact the person or someone knowledgeable about their condition the same day that the absence occurs. If the DAHS facility is unable to contact the person or someone knowledgeable about their condition, the DAHS staff must document this in the person's record. DAHS facilities are not required to notify the caseworker of daily absences from the facility.

4262 DAHS Transfers

Revision 25-2; Effective March 31, 2025

Only the person may initiate a Day Activity and Health Services (DAHS) facility transfer. The change cannot be requested by facility staff.

When a person decides to transfer to a new DAHS facility including a facility in a different region, the person must contact the HHSC caseworker before making the move. The person may make the request to the caseworker verbally or in writing. If a request for a DAHS transfer is received from anyone other than the person, the caseworker must contact the person to ensure they desires the change. Services at the new facility may begin no earlier than one day after the person receives services from the previous facility.

Within 14 calendar days of the request from a current person to transfer to another facility, follow these procedures:

• Negotiate with both facilities the date the current facility will stop providing services and the date the new facility will start services, ensuring there is no gap or overlap in services.
• Update Form 2101, Authorization for Community Care Services, by entering:
  • the nine-digit vendor number;
  • the effective date of the transfer; and
  • a statement in the comments section that this is a transfer.
• Send Form 2101 to the gaining DAHS facility to begin services.
• Send Form 2101 to the losing facility to terminate services.

It is critical for the caseworker to coordinate transfers from one facility to another to ensure that no duplication of service or gaps in dates of coverage exist. Facility-initiated referrals are for applicants only and may not be used for people currently receiving DAHS services.

4263 Suspensions

Revision 23-1; Effective March 1, 2023

The provider agency must suspend services if the recipient:

• permanently leaves the state or moves outside the geographic area served by the program;
• dies;
• is admitted to an institution which is defined as a:
  • hospital;
  • nursing facility;
  • state school;
  • state hospital; or
  • intermediate care facility serving people with an intellectual disability or related conditions;
• requests that services end;
• HHSC denies the recipient’s Medicaid eligibility (not applicable to Title XX DAHS services); or
• exhibits reckless behavior, which may result in imminent danger to the health and safety of the recipient or others.

The provider agency must notify CCSE staff by fax of any suspension by the next business day. The faxed notice of a suspension must include:

• the date of service suspension;
• the reason(s) for the suspension;
• the duration of the suspension, if known; and
• an explanation of the provider agency's attempts to resolve the problem that caused the suspension, including why the problem was not resolved.

CCSE staff confirm the reason for the suspension and take appropriate action. If the suspension results in case closure or termination of DAHS, coordinate closure and the termination date with the provider to allow time for the recipient to receive notification of the right to appeal.

Related Policy 

Service Suspensions, 2820
Service Suspension by Providers, 2821
Service Suspension by Case Workers, 2822
Hospital and Nursing Facility Stays, 2822.1
Refusal to Comply with Service Delivery Provisions, 2830
Suspensions Due to Refusal to Comply with Service Delivery Provisions, 2831
Threats to Health or Safety, 2840

4264 Ensuring Health and Safety at DAHS Facilities

Revision 22-3; Effective Sept. 1, 2022

If a recipient exhibits reckless behavior while at a DAHS facility that may result in imminent danger to the health and safety of DAHS recipients or staff, the DAHS facility must take immediate action to protect recipients and staff in the facility. This may require removing the recipient from the facility or away from others and contacting local authorities such as police, sheriff's department or mental health authorities, to ensure everyone’s safety. The facility may make a referral for appropriate crisis intervention services to the Texas Department of Family and Protective Services (DFPS) Adult Protective Services (APS). The facility must immediately suspend services to the recipient.

The DAHS facility must verbally notify CCSE staff of the reason for the immediate suspension by the following HHSC business day and follow up with written notification to HHSC within seven HHSC business days of the verbal notification. Upon notification, CCSE staff must follow the threats to health or safety policy, including notifying CCSE management of the incident and conferring to ensure all appropriate actions are taken to maintain a safe environment in the facility.

Arrange an interdisciplinary team meeting at the earliest opportunity to determine if the issue can be resolved and services can be continued. If the threat to health and safety was serious enough, services may be terminated immediately.

If the recipient reapplies for services at a later date, they must provide information or authorize collateral contacts to verify they are no longer a threat.

Related Policy 

Effective Dates, 2811
Threats to Health or Safety, 2840
Reinstatement of Services Terminated for Threats to Health or Safety, 2841

4270 Reassessment

Revision 22-3; Effective Sept. 1, 2022

CCSE staff must reassess a DAHS recipient’s eligibility at least every 12 months. The DAHS facility does not need to obtain new physician's orders for recipients receiving ongoing DAHS.

Timelines for DAHS-only cases are measured differently than other case situations because there is no Form 2060, Needs Assessment Questionnaire and Task or Hour Guide, date from which to count. Measure DAHS-only reassessment timelines from the:

• initial contact date (for initial certifications); or
• the previous date on Form 2314, Satisfaction and Service Monitoring, (for recertifications).

When reassessing a DAHS recipient's eligibility, examine the history of attendance. Reauthorize only the number of units the recipient is likely to use. Explore the reasons for underutilization by discussing the situation with the recipient, facility staff and the recipient's family.

If underutilization has been sporadic due to temporary factors such as acute illness or hospitalization, no change in service authorization may be needed. However, if underutilization has occurred consistently during the previous six months, discuss changing the service plan with the recipient and their family. The number of units authorized per week may need to be decreased.

A review of the service plan may be appropriate during the 12-month period if a change in units of service is required.

If CCSE staff determine a recipient continues to be eligible for DAHS but the number of units are changing, submit Form 2101, Authorization for Community Care Services, to the facility. If the facility does not agree with the service plan change, the facility representative must contact CCSE staff before the effective date of the change to resolve the disagreement.

If CCSE staff determine the recipient no longer qualifies for DAHS, send Form 2065-A, Notification of Community Care Services, to the recipient and terminate services. Update and send Form 2101 to terminate services.

Related Policy 

Effective Dates, 2811
Renewal of Prior Approval, 4271
Notification/Effective Date of Decision, Appendix IX
Form 2101 Coverage Dates for Title XIX Services, Appendix XXIII

4271 Renewal of Prior Approval

Revision 25-2; Effective March 31, 2025

Although the coverage period is open-ended in the Service Authorization System, the caseworker must conduct a reassessment or redetermination of the person and send the facility Form 2101, Authorization for Community Care Services, confirming eligibility status if the number of units changes or if services are terminated. Use the following procedures for renewal of prior approval, including late renewals.

4310 Introduction

Revision 26-2; Effective June 1, 2026

Emergency Response Services (ERS) are provided through an electronic monitoring system. This system is for use by people who live alone or with someone who is incapacitated and unable to help if needed. In an emergency, the person can press a call button for help. The electronic monitoring system has a 24/7 monitoring capability to help make sure the appropriate person or service agency responds to a person’s alarm call.

ERS can be delivered to people with a landline phone and may be available to people with cellular phone service or Voice over Internet Protocol (VoIP) in some areas. The provider agency choice list designates which ERS providers in the contracted service area can accommodate applicants who choose to receive ERS without a landline phone. The rates for the service are the same regardless of the ERS delivery mechanism, cellular, landline and VoIP.

Refer to 4312.1 Eligibility

4311 Program Definitions

Revision 25-3; Effective June 1, 2025

The following words and terms, when used in this chapter, mean the following unless the context clearly indicates otherwise:

Alarm call — A signal transmitted from the equipment to the provider's response center. It indicates that the person needs immediate help.

Call button — An electronic device that, when pressed, triggers an alarm to the response center to alert the provider that a person needs immediate help. The device may be held in the hand, worn around the neck, hung on a garment or kept within the person's reach.

Installer — A volunteer, a subcontractor or an employee of a provider who connects, maintains or repairs the equipment.

Monitor — A volunteer, subcontractor or an employee of a provider who monitors Emergency Response Services (ERS) and ensures that an alarm call is responded to immediately.

Responder — A person designated by someone to respond to an emergency call activated by the person. A responder may be a relative, neighbor or a volunteer.

Response center — The site where a provider's ERS monitoring system is located.

Subcontractor — An organization or person who delivers a component of ERS for the provider for a fee and is not an employee or volunteer of the provider.

4312 Eligibility and Referral Procedures

Revision 17-1; Effective March 15, 2017

 

4312.1 Eligibility

Revision 25-4; Effective Sept. 1, 2025

To be eligible for Emergency Response Services, a person must meet the functional need criteria set by the Texas Health and Human Services Commission (HHSC) and meet the following requirements:

• live alone, be alone routinely for eight or more hours each day, or live with an incapacitated person who could not call for help or otherwise help the client in an emergency;
• be mentally alert enough to operate the equipment properly in the judgment of the HHSC caseworker;
• be willing to sign a release statement that allows the responder to make a forced entry into the person’s home if asked to respond to an activated alarm call with no other means of entering the home to respond; and
• live in a place other than a skilled institution, assisted living facility, foster care setting or any other setting where 24-hour supervision is available.

The eight hours mentioned in the rule’s requirement above do not have to be continuous if the person is alone at least eight hours in each 24-hour period. Even if the person has an attendant, consider the person alone.

If the provider cannot complete installation, inform the person that installation of ERS equipment is pending for the reasons the provider stated. If the person is unable or unwilling to make the needed modifications, explore other community resources to determine if these could be used to complete the needed modifications. If none are available, services may then be denied using termination code other. Document the reason in the case record.

Review 3000, Eligibility for Services, for more eligibility requirements.

The person is not eligible for Emergency Response Services if they:

• abuse the service by activating:
  • four false alarms within a six-month period, which result in a response by:
    • fire department,
    • police or sheriff, or
    • ambulance personnel; or
  • 20 false alarms of any kind within a six-month period; or
• are admitted to a skilled institution, personal care home, foster care setting or any other setting where 24-hour supervision is available; and
• are no longer mentally alert enough, in the caseworker's judgment, to operate the equipment properly in situations including but not limited to:
  • damaged the equipment;
  • disconnected the equipment and have received two warnings that are documented in the case record; or
  • refused to participate in the monthly systems checks; or
• are away from the home or cannot participate in the service delivery for a period of three consecutive months or more.

Related Policy

26 Texas Administrative Code Section 271.95 
26 Texas Administrative Code Section 271.155(d) 

4312.2 Referral Process

Revision 24-4; Effective Sept. 1, 2024

A provider must accept all HHSC referrals.  A caseworker makes a routine referral on Form 2101, Authorization for Community Care Services, or makes a negotiated referral by phone and Form 2101.

The caseworker gives eligible applicants an explanation of the services. They explain that applicants or people must:

• participate in the service delivery requirements; and
• have the caseworker review Attachment 2307-B, Emergency Response Services Rights and Responsibilities, with the person, which includes a statement to let the responder enter the participant's home, by force if necessary, to help the participant.

The caseworker follows procedures outlined in 3000, Eligibility for Services.

4313 Case Management Duties Related to Emergency Response Services (ERS)

Revision 24-4; Effective Sept. 1, 2024

If the applicant or person appears to need and also wants to receive ERS, the caseworker determines if the applicant or person meets the criteria for ERS participation.

If eligible for ERS, the caseworker shares the regional list of all ERS providers and the applicant or person selects a provider from this list. If the applicant or person has no preference, the caseworker makes the referral by rotation of providers.

The caseworker may help the person or the provider identify potential responders, and periodically update the information the provider maintains in its files on responders and other emergency numbers. The caseworker must not be an emergency responder for the person.

HHSC rules require the ERS provider notify the caseworker by the next HHSC workday of alarms, other individual emergencies, or changes in the person's behavior or condition that preclude ERS.

At least annually, the caseworker must review the list of responders given to the provider to ensure the list is current. During the services, the caseworker and the provider have the joint responsibility of keeping each other informed of changes or problems.

Report to the contract manager any provider tendency or pattern of designation of emergency personnel as respondents. Advise the person that they are responsible for any charges assessed by emergency personnel if they are summoned to the person's home for a non-medical emergency.

4320 Service Delivery Requirements

Revision 17-1; Effective March 15, 2017

4321 Service Initiation

Revision 21-2; Effective June 1, 2021

When an Emergency Response Service (ERS) provider receives a copy of Form 2101, Authorization for Community Care Services, and the provider packet, they will initiate services.

After receiving the packet, the ERS provider will:

• contact the participant to make an appointment to install the emergency response home unit equipment; and
• prepare a participant file, which includes applicable provider agency forms.

Note: In addition to requesting the applicant’s or recipient’s information, the provider will also complete a home entry release statement, ownership of equipment statement, and complaint procedure form.

If a different service initiation date is required, the provider must contact Community Care Services Eligibility (CCSE) staff to negotiate the new service initiation date by which services must begin.

Evaluate if an alternative service or other resources are available to meet the person’s needs. Instruct the provider to retain the authorization and initiate services as soon as possible or request the return of the written referral packet.

Related Policy

Content of Referral Packets, Appendix XIII

4322 Reserved for Future Use

Revision 22-2; Effective June 1, 2022

4323 Reserved for Future Use

Revision 22-2; Effective June 1, 2022

4324 Provider Follow-Up Procedures

Revision 25-3; Effective June 1, 2025

The provider notifies the caseworker of service initiation as outlined in 4321, Service Initiation.

The provider maintains ongoing communication with the caseworkers and the regional contract manager. They discuss person specific issues with the caseworker, and contract management issues overall service delivery, policies and procedures with the regional contract manager.

4325 Selection of Providers and Provider Changes

Revision 24-4; Effective Sept. 1, 2024

Each region maintains a list of all Emergency Response Services (ERS) providers. The list includes:

• vendor number;
• geographic areas served.

This information is given to the recipient to help make an informed choice. The recipient must select an ERS provider from the regional list. If the recipient does not have a preference, refer to the next provider on a rotating basis.

The recipient must contact Community Care Eligibility Services (CCSE) staff to request a provider change. CCSE staff determine:

• the issue or reason for the change request;
• if the issue can be addressed without changing providers; and
• if the provider will agree to the transfer.

Before processing a transfer, try to resolve the recipient’s concerns with the current provider.

If the issue with the provider is based on the recipient's failure to comply with the service plan, convene an interdisciplinary team (IDT) meeting to discuss the issues. If services are not terminated due to the recipient’s failure to comply with the service plan, authorize a transfer if necessary to address the recipient's concerns or if the recipient insists on changing providers.

Have the recipient select another provider and process the transfer. Coordinate the date the current provider ends services and the date the new provider begins services. An ERS provider may receive payment for the month of service regardless of the number of days services were provided in the month services were terminated. During a transfer of ERS services, make every effort to end the service of the first provider on the last day of the month and begin service of the second provider on the first day of the following month. Coordination of the end and begin dates reduces the need for payment of services to a second ERS provider for the same calendar month.

Related Policy

Suspension and Termination of Services, 4340

4330 Service Delivery

Revision 17-1; Effective March 15, 2017

4331 Reserved for Future Use

Revision 22-2; Effective June 1, 2022

4332 System Checks

Revision 24-4; Effective Sept. 1, 2024

An ERS recipient must be able to participate in monthly system checks. The monthly system check ensures that the recipient can successfully make an alarm call and that the equipment works properly.

If a provider cannot complete a system check during a calendar month, they must notify CCSE staff in writing.

Once notified that the provider cannot complete a system check, convene an IDT to evaluate the situation. Determine if the recipient continues to be appropriate for the service. If continuing services, complete and return Form 2067, Case Information. If terminating services, complete Form 2101, Authorization for Community Care Services.

Allow the authorization for ERS to remain effective if the recipient is still eligible for the service but cannot participate in a monthly system check.

Ensure the recipient's authorization does not exceed three consecutive billing months in which the recipient cannot participate in the monthly system checks.

4333 Equipment Malfunction

Revision 25-3; Effective June 1, 2025

A provider must contact the recipient by the next day after learning of any equipment failure. They must replace the equipment if the recipient is available within one business day or by the end of the third day if the recipient is not available the first business day.

The provider must ensure the equipment is functioning properly and that each recipient receives services during the entire authorization period.

The following people may report equipment malfunctions to the provider:

• recipient;
• recipient's family members;
• recipient's responders;
• CCSE staff; and
• monitors.

Providers:

• Send the installer to the recipient's home to repair or replace the equipment as equipment malfunctions are reported.
• Keep a record of each equipment malfunction in the provider's files.
• Must visit a recipient's home to check the equipment within five business days after the equipment has registered five or more low battery signals in a 72-hour period.
• Must replace a defective battery during the visit to the recipient’s home to check equipment.
• Must respond to low battery signals received from the recipient's equipment.
  • Provider staff must contact the recipient by phone after receiving a low battery signal to determine if the low battery could be caused by an accident, such as the unit having been unplugged.
  • If the low battery signals continue, the provider must send a staff member to check, and repair or replace the recipient's ERS equipment within five business days after the receipt of the fifth low battery signal.

4340 Suspension and Termination of Services

Revision 24-4; Effective Sept. 1, 2024

An interdisciplinary team (IDT) meeting may be called by Community Care Services Eligibility (CCSE) staff or provider staff, if monthly system checks are unsuccessful or a recipient or someone in their home engages in illegal discrimination against a provider staff or Texas Health and Human Services Commission (HHSC) staff. Send Form 2067, Case Information, to notify the provider, if services continue. Send Form 2101, Authorization for Community Care Services, to terminate services, if services are terminated because of the IDT.

Report any changes involving the recipient to the provider. Example: hospitalization, change of residence, or visits with relatives.

A provider may leave ERS equipment in a recipient's home and continue service delivery when the recipient has temporarily entered an institution. The provider must suspend services if the recipient has been in the institution for more than 120 consecutive days. The provider is eligible for payment if the system checks are conducted during the 120-day period.

The provider must request termination of services when the recipient is no longer competent enough to operate the equipment properly. Situations include, but are not limited to, when the recipient:

• damages the equipment;
• disconnects the equipment and has received two warnings that are documented in the case record; or
• refuses to participate in the monthly system checks.

Providers:

• Must document the inability to test the home unit in the recipient’s case file.
• Request the installer remove the equipment from the recipient’s home after CCSE staff authorize service termination.
• May leave ERS equipment in a recipient’s home and continue services until the end of the month the service authorization expires.
• Receives payment for the month the service authorization ends, if:
  • monitoring continues until the equipment is picked up; and
  • the equipment is tested during the same calendar month or at the time of pickup.
• May be paid for the last month of service if ERS is terminated, regardless of how many days of service were provided in that month, if the provider has complied with ERS requirements.

The recipient is not responsible for payment for lost or damaged equipment.

4341 Interdisciplinary Team (IDT) Meeting

Revision 24-4; Effective Sept. 1, 2024

CCSE staff or the provider staff will set up an IDT meeting as needed. Call a meeting for situations where the provider cannot resolve issues with the recipient. CCSE staff must participate in the IDT meeting to help resolve issues. The IDT meeting could result in the continuation or discontinuation of services. If applicable, policy relating to failure to comply with the service plan must be considered.

4350 Reserved for Future Use

Revision 22-2; Effective June 1, 2022

4351 Advertising and Solicitation

Revision 25-3; Effective June 1, 2025

HHSC may investigate complaints of solicitation or coercion of people. Validated complaints may lead to adverse actions or termination of contracts. The ERS provider is in violation of the ERS contract if the provider employs a person:

• who is paid money each time they recruit a new Medicaid recipient; or
• whose sole responsibility is recruitment, no matter how they are compensated.

The ERS provider may have an employee who is responsible for recruitment and other assignments, if they are paid a regular salary and do not receive bonuses or anything that could be construed as a bonus for recruitment of Medicaid recipients.

4352 Disclosure of Previous Employment and Certification

Revision 24-4 Effective Sept. 1, 2024

The commissioner of Texas Health and Human Services Commission (HHSC) or designee must approve the contract or contract renewal if a former or current HHSC employee, former or current council member, or their relatives are an officer, director, owner or employee.

4353 Reserved for Future Use

Revision 22-2; Effective June 1, 2022

4360 Reassessment

Revision 26-2; Effective June 1, 2026

Reassess eligibility within 12 months of the last functional assessment for services. Call or make a home visit to redetermine the person's eligibility for ERS. During the visit, ask the person to explain how to initiate an alarm call. Evaluate if the person continues to be sufficiently mentally alert to operate the equipment. Review 4312.1, Eligibility.

If the person continues to be eligible and with no changes, do not send anything to the provider. If services are terminated, coordinate the effective date of termination to match on Form 2065-A, Notification of Community Care Services, and Form 2101, Authorization for Community Care Services, to allow the person 12 calendar days prior notice.

4410 Family Care

Revision 25-2; Effective March 31, 2025

Family Care (FC) provides in-home Personal Attendant Services (PAS) to people eligible under Title XX of the Federal Social Security Act relating to block grants to states for social services. Providers delivering PAS must meet all the requirements in Title 26 Texas Administrative Code Section 277.11, Contracting Requirements.

Review 4600, Primary Home Care and Community Attendant Services, for information on the Title XIX programs.

4411 Family Care Services Description

Revision 25-2; Effective March 31, 2025

Family Care (FC) provides help with activities of daily living to eligible people with functional limitations caused by age, disabilities or medical problems. Services are limited to 50 hours per week and 42 hours per week for a priority person. Services include help with personal care, household tasks, meal preparation and escort.

FC is a non-skilled, non-technical service delivered by an attendant employed by the provider. The attendant must be 18 or older. Providers must comply with the requirements in the contract with the Texas Health and Human Services Commission and in the Contracting to Provide Primary Home Care Services Handbook.

4412 Allowable Tasks

Revision 25-4; Effective Sept. 1, 2025

Personal attendant services (PAS) that may be delivered under Family Care (FC) include the tasks defined in 26 Texas Administrative Code (TAC) Section 277.41, Allowable Tasks.

For information on escort services, refer to 26 TAC Section 271.83(a) and (b), Time Allocation for Escort Services.

Refer to the examples given in 4621, Allowable Tasks, for more information on calculating time for escort. Escort may include accompanying the person on non-medical trips such as the grocery store, paying bills, pharmacy, hair stylist or barber, or social events. The time used to provide the escort task must not exceed the total time purchased for attendant care. No additional time for escort is allocated to the person’s service plan. The person may elect to receive escort in place of help with household or personal care on a day that best meets their needs. This service does not include the direct transportation of the person by the attendant.

Because shopping is an authorized task, it may entail the provider paying mileage to the attendant to perform the task. The person cannot be charged for transportation costs incurred when this task is performed by either the attendant or the provider.

Arranging furniture may be provided to improve mobility for people who use wheelchairs, walkers or crutches, or for blind people. The provider supervisor addresses this activity during orientation for an attendant who provides services to this type of person.

Refer to pages three and four of Form 2060, Needs Assessment Questionnaire, Task and Hour Guide, for more definition of activities that may be provided within each task.

4413 Excluded Services

Revision 25-3; Effective June 1, 2025

Family Care (FC) does not include services that must be provided by a person with professional or technical training. Examples include but are not limited to the following:

• insertion and irrigation of catheters;
• irrigation of body cavities;
• application of sterile dressings involving prescription medications and aseptic techniques;
• tube feedings;
• injections;
• administration of medication; and
• any other skilled or technical services identified by the department.

Services that maintain an entire family or household are also excluded unless the entire household receives Community Care Services Eligibility services. Examples include:

• cleaning floor and furniture in areas that the person does not occupy or use;
• preparing meals for the entire family or household;
• laundering clothing or bedding that the person does not use; and
• shopping for groceries or household items the person does not need for health and maintenance.

An attendant may shop for items the person needs and that the rest of the household also uses.

4420 Eligibility

Revision 26-1; Effective March 1, 2026

To be eligible for family care, the applicant or person must:

• meet the income and resource guidelines established by the Texas Health and Human Services Commission (HHSC) in 26 Texas Administrative Code Sections 271.53, 271.55, 271.89, 271.91 relating to Income and Income Eligibles, Determination of Countable Income, Resource Limits and Countable Resources;
• meet the minimum functional need criteria set by HHSC:
  • HHSC uses a standardized assessment instrument to measure the person’s ability to perform activities of daily living;
  • this yields a score, which is a measure of the person’s level of functional need;
  • HHSC sets the minimum required score for a person to be eligible, which it may periodically adjust commensurate with available funding;
  • HHSC will seek stakeholder input before making any change in the minimum required score for functional eligibility; and
• be ineligible to receive attendant care services funded through Medicaid.

The applicant or person must require at least six hours of family care per week to be eligible, unless the applicant or person:

• requires family care to provide caregiver support;
• lives in the same household as another person receiving family care, community attendant services or primary home care;
• receives one or more of the following services through HHSC or other resources:
  • congregate or home-delivered meals;
  • help with activities of daily living from a home health aide;
  • day activity and health services; or
  • special services to persons with disabilities in adult day care;
• receives aids-and-attendance benefits from the Veterans Administration; or
• is determined, based on the functional assessment, to be at high risk of institutionalization without family care.

Review the following for eligibility policy not contained in this section:

• Eligibility for CCSE Services, 3110
• Age Limits, 3111
• Resource Eligibility Criteria, 3200

4421 Residence

Revision 25-4; Effective Sept. 1, 2025

To receive services, the person must live in a place other than:

• a hospital;
• a skilled nursing facility;
• an intermediate care facility;
• an assisted living facility;
• a foster care setting;
• a jail or prison;
• a state school;
• a state hospital; or
• any other setting where sources outside the primary home care program are available to provide personal care.

Family Care (FC) cannot be authorized if the person lives in a home licensed as a personal care home by the Texas Department of State Health Services. If the home is not a licensed personal care home, services may be authorized if:

• three or fewer people live in the home. The proprietor can be the personal attendant services (PAS) attendant for the people who live there. The person may not receive both PAS and Adult Foster Care.
• the home provides only room and board to four or more people living in the home, it does not require licensure as a personal care home. PAS services can be authorized for people in this setting, but the proprietor, their agent or employee cannot be the attendant for people who live in the home. The caseworker must specify this on Form 2101, Authorization for Community Care Services.

FC can be provided to a private pay applicant or person living in a residential care facility if contracted with HHSC or not, under the following conditions.

• The caseworker applies the unmet need policy on a task-by-task basis, not duplicating services.
• Facilities provide varying degrees of assistance, and tasks purchased should not be tasks provided by the facility.
• The caseworker must closely monitor the case to find out if the person is receiving other services from the facility. Service plans must be adjusted to avoid duplication of services or tasks.

If the person begins receiving residential care (RC) through HHSC, FC is terminated effective by the date RC services are started.

Related Policy

26 Texas Administrative Code Section 271.81(b)  

4430 Caseworker Procedures for Determining Eligibility

Revision 25-3; Effective June 1, 2025

Review 2200, Intake Procedures, for intake, screening criteria and interest list procedures.

Upon receipt of a Family Care intake or release from the interest list, the caseworker makes a home visit within the required time frames to begin the application process.

Conduct a home visit to determine if the person meets eligibility criteria outlined in 4420, Eligibility. The applicant must provide information to determine financial eligibility outlined in 3000, Eligibility for Services, and must be screened for eligibility for Community Attendant Services (CAS).

Give the following to all applicants:

• Form 2307, Rights and Responsibilities;
• Attachment 2307-A, Family Care, Community Attendant Services and Primary Home Care Rights and Responsibilities; and
• Attachment 2307-EVV, Electronic Visit Verification Rights and Responsibilities, when the applicant requests CAS, Primary Home Care or Family Care services.

Explain that the caseworker must approve increases in the number of hours of services the person receives. Also inform the person that they may select another provider if they are dissatisfied with the services or with the attendant providing the services.

4431 Family Care Financial Eligibility

Revision 25-4; Effective Sept. 1, 2025

To be eligible for family care, the person must:

• meet the income and resource guidelines established by the department in 26 Texas Administrative Code Sections 271.53, 271.55, 271.89 and 271.91, which relate to Income and Income Eligibles, Determination of Countable Income, Resource Limits, and Countable Resources;
• be ineligible to receive attendant care services funded through Medicaid.

The caseworker must determine that an applicant for Family Care is not eligible for services through Primary Home Care (PHC) or Community Attendant Services (CAS). Review 2340, The Initial Interview and Application Process, for information on the determination of financial eligibility and screening for eligibility for CAS.

Review 3000, Eligibility for Services, and Appendix XII, Examples of Methods to Verify Income and Resources, for specific information on determining financial eligibility.

4432 Family Care Functional Eligibility

Revision 25-4; Effective Sept. 1, 2025

Regardless of a person’s functional eligibility as determined by their score on the client needs assessment questionnaire, a person only receives CCSE services if there is an unmet need for those services.

Applicants and people must score at least 24 on Form 2060, Needs Assessment Questionnaire, Task and Hour Guide, to be eligible for Family Care.

Review 2400, Assessment Process, 2500, Service Planning, and 2600, Authorizing and Reassessing Services, for caseworker procedures for full determination of functional eligibility and unmet need determination.

Related Policy

26 Texas Administrative Code Section 271.61
26 Texas Administrative Code Section 271.69  

4433 Time Frames

Revision 25-4; Effective Sept. 1, 2025

Eligibility for CCSE services for income-eligible applicants is determined within 30 calendar days after a signed application is received.

The caseworker must complete all eligibility determination within 30 calendar days from the assessment date and send the applicant Form 2065-A, Notification of Community Care Services, within two business days of the eligibility decision.

Related Policy

26 Texas Administrative Code Section 271.151(d) 

4440 Referral Process

Revision 21-4; Effective December 1, 2021

After completing the assessment, send the selected provider a referral packet.

The referral packet must include:

• a cover sheet;
• the Long-term Care Services Intake system (NTK) generated Form 2110, Community Care Intake; and
• copy of the following Service Authorization System Online Wizards (SASOW) generated forms:
  • Form 2059, Summary of Client's Need for Service;
  • Provider Referral Supplement;
  • Form 2060, Needs Assessment Questionnaire and Task/Hour Guide;
  • Task/Hour Guide; and
  • Form 2101, Authorization for Community Care Services.

All Form 2101 referrals to the provider, both initial and ongoing, must include the:

• authorized tasks;
• total number of authorized hours;
• number of days the applicant or recipient requests delivery of services; and
• relationship and name of any person designated as ‘do not hire.’

Document any of the following information in the comments section of the Form 2101:

• any special needs of the applicant or recipient that require a specific schedule and the reason;
  
  Example: “<Name of person> is diabetic and requires a specific eating schedule.” or “<Name of person> requires service delivery in the afternoon due to a sleeping condition.”
   
• the number of service days requested by the applicant or recipient based on the Form 2060;
  
  Example: "<Name of person> requests a five-day plan."
   
• the relationship and name of any person(s) designated as ‘do not hire;’
  
  Example: “Do not hire <spouse>, <name of spouse>, for any tasks.” or “Do not hire <daughter>, <name of daughter>, for shopping.”

Related Policy

Who Cannot Be Hired as the Paid Attendant, 2514
Referrals to the Provider, 2630
Content of Referral Packets, Appendix XIII

4440.1 Types of Referrals

Revision 25-3; Effective June 1, 2025

There are two methods of referral:

• For expedited referrals, the caseworker makes the referral by verbal notice and on Form 2101, Authorization for Community Care Services.
• For routine referrals, the caseworker makes the referral on Form 2101.

Routine Referrals

Within five business days of the eligibility decision, the caseworker mails the referral packet to the provider to authorize service delivery.

Expedited Referrals

Sometimes the person's need for services must have facilitated delivery of services. This is based on the caseworker's judgment. When weighing if an expedited referral is warranted, consider:

• What was the person's assigned intake priority? In most situations, cases which required an expedited response to a request for services also require an expedited referral.
• Is the applicant being authorized as having priority status? If so, that may indicate a need for an expedited referral.
• Could a delay in starting services constitute a threat to the person's health, safety or well-being? If so, an expedited referral is needed.

The expedited referral process includes:

• the caseworker makes a verbal referral to the selected provider and negotiates a start of care date which must be less than 14 calendar days once the eligibility decision is made; and
• following up the verbal referral by sending a referral packet to the provider, including Form 2101, Authorization for Community Care Services, noting the time, date and staff person contacted, and the negotiated start date in the comments section.

4441 Provider Responsibilities after Receipt of Referral

Revision 25-4; Effective Sept. 1, 2025

Upon receipt of the referral packet, the provider must conduct pre-initiation activities, develop a service plan and assign an attendant to perform services for the individual in accordance with 26 Texas Administrative Code (TAC) Section 277.45. These activities must be completed within 14 days after one of the following dates, whichever is later:

• the referral date on Form 2101, Authorization for Community Care Services; or
• the date the provider receives Form 2101, unless the provider fails to stamp the receipt date on the form, in which case the referral date will be used to determine timeliness.

For expedited referrals, the provider must document the date, time and the name of the caseworker who gives the verbal authorization. Provider staff contact the caseworker if the packet is not in their office by the seventh day after the verbal referral.

The provider can request a corrected authorization if the information, such as hours or dates of coverage, conflicts with what was given over the phone. In these situations, correct and initial Form 2101 and mail a copy of it to the provider.

Within 14 days after initiating services, the provider must send notice of service initiation to the caseworker. The provider may, but is not required, to use Form 2101 to notify the caseworker of service initiation.

4441.1 Delay of Service Initiation

Revision 25-4; Effective Sept. 1, 2025

26 Texas Administrative Code Section 277.61 Service Initiation.

A provider may delay the start of service only if the reason is not directly caused by the provider or is beyond the provider’s control, such as natural or other disasters. The provider must continue efforts to begin services and set a date, if possible, for service initiation. The provider must document any failure to begin services by the relevant due date, including:

• the reason for the delay, which must be beyond the provider's control;
• either the date the provider thinks they will initiate services or specific reasons the provider cannot anticipate a service initiation date; and
• a description of the provider's ongoing efforts to begin services.

The provider must maintain documentation of service initiation in the person's file.

4441.2 Initial Service Delivery Plan Variances

Revision 25-4; Effective Sept. 1, 2025

Providers must follow the rules as specified in 26 Texas Administrative Code Section 277.45(b), Pre-Initiation Activities.

4442 Resolution of Service Plan Disagreement

Revision 25-3; Effective June 1, 2025

If a disagreement exists about the appropriateness of a referral or about service delivery issues involving the person, the caseworker and the provider staff attempt to resolve the disagreement. If the disagreement is not resolved at this level, supervisory staff of the two agencies attempt to resolve it. If supervisory staff of both agencies cannot resolve a disagreement, the regional director or designee resolves it. Do not delay service initiation because of a disagreement. The regional nurse may always be consulted about health and safety issues or the appropriateness of the service plan.

4443 Change of Providers

Revision 25-3; Effective June 1, 2025

Monitor the person after services are initiated and at times after that to check on the adequacy of the service plan, the quality-of-service delivery and the person's condition. Report to the unit supervisor any apparent deficiencies in the provider's delivery of Family Care (FC) services.

When a person plans to change providers, they must first contact their caseworker, who will:

• coordinate the transfer to prevent a gap in coverage; and
• try to resolve any problems the person may have with their current provider before processing the transfer.

Within 14 calendar days of notification that an ongoing FC person is requesting a transfer to another provider, the caseworker contacts the person and the provider to determine:

• the person's reason for dissatisfaction; and
• if the person's satisfaction can happen without changing providers.

The caseworker may decide that an interdisciplinary team (IDT) meeting is fitting to discuss and find a solution to the service delivery issues. Review 4675, Interdisciplinary Team, for more information. The caseworker may terminate the person’s services for refusal to comply with the service delivery provisions. This would be because the person, more than three times repeatedly directly, or knowingly and passively, condoning the behavior of someone in their home.

The caseworker authorizes the transfer within three business days of the IDT decision if:

• they determine that the person’s satisfaction cannot be met without the person changing providers and services do not have to be terminated based on failure to comply with the service plan; or
• the person insists on transferring to another provider and the caseworker determines that services do not have to be terminated based on failure to comply the service plan.

Within those three business days, the caseworker also:

• asks the person or the person’s representative to select a new provider and documents the person’s choice by:
  • coordinating with both providers the date the current provider will stop providing services and the date the new provider will start services;
  • updating any pertinent information on Form 2059, Summary of Client’s Need for Service;
  • updating Form 2101, Authorization for Community Care Services, for ongoing cases by entering the nine-digit contract number in Item 2; and
  • documenting in the comment section the coordination with both providers and the effective date of the change.
• sends the new provider the updated Form 2101 and Form 2059; and

sends the current provider a copy of the updated Form 2101 that includes the effective date the person changes to the new provider.

4443.1 Service Interruptions

Revision 25-4; Effective Sept. 1, 2025

Refer to 26 Texas Administrative Code (TAC) Section 277.63(a), Service interruptions.

A service interruption occurs anytime service delivery is discontinued for 14 days or more for a reason that is not covered in 4446, Suspension of Services and Interdisciplinary Team (IDT) Procedures. The provider should make every effort to make sure interruptions in service last less than 14 days, particularly if a break in service would jeopardize the person’s health or safety. When an interruption of services is unavoidable, the provider must document all service interruptions by the 30th day:

• after the beginning of the service interruption for priority people, and
• that exceeds 14 days after the service interruption for non-priority individuals.

4444 Reporting Significant Changes

Revision 25-3; Effective June 1, 2025

The provider notifies the caseworker or the caseworker's office by phone or in person about a change in the person's condition or circumstances that may require a service plan change or service termination.

The provider must notify the caseworker by the first Texas Health and Human Services Commission one business day after provider staff notice the change. They must follow up in writing, using Form 2067, Case Information, within seven calendar days after verbal notification.

Any of the following changes in the person's condition or circumstances may require a change in their service plan. These are examples only. This list is not all inclusive.

• the person’s health improves or deteriorates;
• the person no longer needs services;
• the person is discharged from a hospital;
• problems exist with family relationships;
• the person is evicted or otherwise loses their housing;
• the person relocates;
• the person is referred for home health services; and
• changes occur in the person's household composition.

If the caseworker receives a request for a change, respond to it within 14 calendar days from the date the request is received. Review the person's service plan to decide if the change is necessary. If the caseworker decides the change is not necessary, document the decision on Form 2067, send it to the provider and send Form 2065-A, Notification of Community Care Services to the person. Document the reason and related handbook reference for the denial of the requested change in Form 2065-A comments section.

A new assessment or revision of the service plan such as a change in priority status or a need for more hours may be necessary, depending on the person's new condition or situation. If appropriate, make changes to the service plan on Form 2101, Authorization for Community Care Services, per 2720, Changes Reported in the Individual's Condition or Status during the Certification Period. Consult with the supervisor about the requested change, if necessary. If the report meets the criteria for Adult Protective Services (APS), refer the individual to that service. Review 2220, Response to Requests for Service.

Related policy

Title I, Texas Administrative Code, Part 15, Chapter 357, Subchapter A
2910, Person’s Right to Appeal and Request a Fair Hearing

4445 Service Plan Changes

Revision 25-3; Effective June 1, 2025

Mail two copies of Form 2101, Authorization for Community Care Services, and one copy of Form 2059, Summary of Client's Need for Service, to the provider if a service plan change is authorized. If a service plan change increases hours, the beginning date of coverage is seven calendar days from the Form 2101 date, unless an earlier date is negotiated. Use verbal referral procedures for new priority recipients if a service plan change adds priority status.

For a service decrease or termination, the provider must abide by Community Care Services Eligibility (CCSE) staff's 12 calendar days prior notice provided to the recipient before implementing the change. CCSE staff must advise the provider using the comments section on Form 2101, if applicable, not to implement an adverse action until after the 12-calendar day notice. The recipient may appeal the decision and choose to continue to receive services pending the outcome of the appeal. These time frames apply only to those cases when the provider has a current authorization for the recipient.

When the recipient requires an immediate change to the service plan, approve the change by phone or in person. Respond by the next business day when any of the following situations occur:

• The recipient has a major illness and no available caregiver.
• The recipient loses their caregiver suddenly, has no other available caregiver, and
  • is totally bedridden or unable to transfer from bed to chair without help;
  • cannot manage toileting tasks without personal assistance; or
  • needs meal preparation or feeding to ensure that they receive daily nourishment.

If necessary:

• verbally authorize a service plan change;
• initial the service arrangement column on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide; and
• send two copies of Form 2101 to the provider within two business days of the verbal request.

Related Policy

Priority Status, 2540
Negotiated Referrals, 2631
Time Calculation, Appendix XVIII

4446 Suspension of Services and Interdisciplinary Team (IDT) Procedures

Revision 25-3; Effective June 1, 2025

The provider agency must suspend services if:

• the person permanently leaves the state or moves to a county where the provider agency does not contract with the Texas Health and Human Services Commission (HHSC) to provide services under the Primary Home Care Program. Review 4677.1, Person Temporarily Leaving Service Area;
• the person moves to a location where services cannot be provided under the Primary Home Care Program; or
• the person dies;

Note: Complete and send Form SSA-1610-U2, Public Assistance Agency Information Request when notified of an active SSI or Medicaid person's death, to report the death of the person to the Social Security Administration. Keep a copy of Form SSA-1610-U2 and file in the case record.

• the person is admitted to an institution. An institution is defined as a:
  • hospital;
  • nursing facility;
  • state school;
  • state hospital; or
  • intermediate care facility serving people with an intellectual disability or related conditions;
• the person requests that services or specific tasks end;
• HHSC denies the person’s Medicaid eligibility not applicable to family care services; or
• the person or someone in the person’s home exhibits reckless behavior, which may result in imminent danger to the health and safety of the person, the attendant, or another person;
• if this reckless behavior occurs, the provider agency must make an immediate referral to:
  • the Texas Department of Protective and Regulatory Services or other appropriate protective services agency;
  • local law enforcement, if appropriate; and
  • the person’s case worker.

Services may be suspended indefinitely if the person is admitted to a rehabilitation hospital or to a rehabilitation floor or wing of a medical hospital.

The provider agency may also suspend services if:

• the person or someone in the person’s home engages in discrimination against a provider agency or HHSC employee in violation of applicable law; or
• the person refuses services for more than 30 consecutive days.

The provider agency must notify the caseworker by fax of any suspension by the next working day. The faxed notice of a suspension must include:

• the date of service suspension;
• the reason(s) for the suspension;
• the duration of the suspension, if known; and
• an explanation of the provider agency's attempts to resolve the problem that caused the suspension, including the reasons why the problem was not resolved.

The provider agency must convene an interdisciplinary team (IDT) meeting to resume services.

The provider agency must resume services after suspension:

• once the person returns home, or the date the provider agency becomes aware of the person returning home, if applicable;
• on the date specified in writing by the caseworker;
• because of a recommendation by the IDT; or
• upon the provider agency's receipt of notification from the caseworker that the provider agency must resume services pending the outcome of the appeal.

The provider agency must notify the caseworker in writing of the date services resume and must send the notice within seven calendar days of that date.

4447 Reassessment

Revision 26-1; Effective March 1, 2026

Functional Assessment

Functional eligibility must be redetermined for Family Care (FC) at least every 12 months. At each annual functional reassessment, review the screening exception criteria and determine if the recipient’s circumstances have changed.

For example, refer the person to Primary Home Care (PHC) or Community Attendant Services (CAS) if they were placed on FC because of no personal care tasks, but at the annual reassessment now require a personal care task.

Apply the screening exception criteria at the next annual review if the recipient or provider report interim changes between annual reassessments.

If a recipient requests a change at the annual reassessment, the change must be worked within five business days or by the annual reassessment due date, whichever is earlier.

Financial Assessment

Determine financial eligibility for FC at least every 24 months. If the person was previously determined ineligible for CAS because of resources, review the recipient’s current financial information.

If the recipient appears to meet the financial requirements for CAS, send Form H1200, Application for Assistance – Your Texas Benefits, along with verifications of income and resources to Medicaid for the Elderly and People with Disabilities (MEPD) for a CAS financial determination.

If a recipient was determined eligible for FC because of receipt of QI-1 benefits, reverify QI-1 benefits at each financial reassessment.

Note: If the person is referred to MEPD for CAS and is denied because of income or resources, the caseworker must review the reason for denial and make sure the person continues to meet financial eligibility requirements for Title XX. If the countable income or resources are over the Title XX limits the FC case must be denied. Refer to 3200, Resource Eligibility Criteria and 3300, Income Eligibility.

Related Policy

Exception Criteria for Referrals to PHC or CAS, 2342.2
Exceptions to Verification Requirements, 3422
Content of Referral Packets, Appendix XIII

4448 Complaints

Revision 25-3; Effective June 1, 2025

A person has the right to:

• voice grievances or complaints about the Texas Health and Human Services Commission (HHSC) staff or purchased services without discrimination or retaliation; and
• report service delivery issues to the Texas Health and Human Services (HHS) Office of Ombudsman at 877-787-8999.

If the caseworker is aware of the issue, the caseworker must work to resolve the person's issues. Review policy outlined in 2736.1, Reporting Service Delivery Issues, for detailed procedures in handling service delivery issues.

4510 Description

Revision 25-4; Effective Sept. 1, 2025

Home-Delivered Meals (HDM) provides nutritious meals typically served in the person's home. Meals may be delivered to alternate locations if the location is within the provider's standard service delivery area.

Example: A person receives dialysis treatments on Mondays, Wednesdays and Fridays. Because the treatment center is within the provider's standard service delivery area, HDMs can be delivered to that location on the days the person receives treatments.

When the person must regularly receive meals in an alternate location outside the service area, shelf-stable or frozen meals may be delivered to the person's home for use in the other location. The caseworker must check with the contract manager to make sure the provider's contract allows delivery of shelf-stable or frozen meals.

Meals delivered by contracted providers are approved by a dietitian consultant who is either a registered dietitian licensed by the Texas State Board of Examiners of Dietitians or has a bachelor’s degree with major studies in food and nutrition, dietetics or food service management.

Related Policy

26 Texas Administrative Code (TAC) Section 2881.15, Menus
26 TAC Section 281.19, Modified Diets
26 TAC Section 281.11, Nutrition Education

4520 Eligibility

Revision 25-5; Effective Dec. 1, 2025

People who apply for or receive Title XX meals are not subject to an income and resource eligibility determination.

A person must score at least 20 on Form 2060, Needs Assessment Questionnaire, Task and Hour Guide, to be functionally eligible for Home-Delivered Meals.

Related Policy

26 Texas Administrative Code Section 271.71 

4521 Home-Delivered Meals Interest List Procedures

Revision 26-2; Effective June 1, 2026

If Title XX Home-Delivered Meals (HDM) funds are unavailable when a person requests that service, add the person's name to the HDM Interest List(s) by entering the information in the Community Services Interest List (CSIL) system. People who request placement on an interest list must be Texas residents. Names are released from the interest list on a first-come, first-served basis. Eligibility determinations are conducted as funds become available. Review 2230, Interest List Procedures.

If the person is receiving meals through another service, the caseworker must find out if the meals are through a temporary service. Several community organizations offer temporary delivery of meals until another source is available. Meals received through the Area Agency on Aging (AAA) via Title III are limited and only meant to provide temporary assistance to people. Meals provided through other local organizations may also be temporary.

If a person requests HDM through Title XX and currently receives meals, the intake person records the current meal source. The person must not be screened out because they receive meals from another source. The intake person completes the intake and either refers to a caseworker for assessment, if the region has open enrollment, or places the person's name on the interest list. The same policy applies when a person receiving other CCSE services requests Title XX HDM. The applicant or person may continue to receive temporary meals while on the interest list for Title XX HDM.

When the caseworker receives the request for services or a person's name is released from the interest list, the caseworker must find out if the current meal source is ongoing or temporary. If the applicant or person states the meals are ongoing, the caseworker must verify with the source and document that the meals are ongoing. The applicant or person can choose between Title XX HDM and the other source. The caseworker must document the applicant's or person's decision and follow procedures for approving or denying the service request.

If the source is a temporary service, the applicant must be authorized for Title XX meals if all other eligibility requirements are met. Service initiation through Title XX meals must be coordinated with the termination of the temporary service and documented in the case record.

4530 Casework Procedures

Revision 17-1; Effective March 15, 2017

4531 Service Initiation

Revision 25-4; Effective Sept. 1, 2025

To refer people to providers for Home-Delivered Meals (HDM), complete Form 2101, Authorization for Community Care Services, and send the referral packet to the selected provider. Review Appendix XIII, Content of Referral Packets. The provider must initiate services within 10 calendar days from the date of referral and return Form 2101 to the caseworker within 21 calendar days.

Inform the provider of any special circumstances relevant to the person's service provision. Specify on Form 2101 that the provider must deliver meals prepared without added salt as seasoning or flavoring, when necessary for the person's health. Ensure that the person understands when the home-delivered meals will be delivered, their responsibility for receiving the meals and that they are not responsible for contributing or paying for them.

Reassess the persons eligibility for services annually, within 12 months of the previous functional assessment.

Note:  Coordinate services with the local Area Agency on Aging to ensure there is no service duplication of home-delivered meals

Related Policy

26 Texas Administrative Code Section 281.25, Service Initiation.

4532 Person's Health and Safety

Revision 25-3; Effective June 1, 2025

A provider agency must have written procedures in place to ensure it investigates and reports to the appropriate persons or entities any significant changes in the person’s physical or mental condition or environment. These procedures must require the following:

• The provider agency notifies a person’s caseworker, verbally or by fax, within one business day after becoming aware of significant changes in the person’s physical or mental condition or environment.
• If the provider agency notifies the caseworker verbally, the provider agency must send written notification to the case worker within five business days of the initial verbal notification.

A provider agency must inform the person about safety, health, or fire hazards identified in the person’s home when the provider agency discovers these hazards. The provider agency must keep documentation of such communications in its files, per the terms of the contract.

A provider agency must notify the Texas Health and Human Services Commission (HHSC) personnel, verbally or by fax, within one business day after an incident that may prevent the provider agency from delivering meals to one or more people.

A reportable incident includes:

• weather-related emergency;
• fire; or
• other natural disasters.

The provider agency must report an incident to:

• the contract manager;
• the person’s caseworker or supervisor.

If the provider agency notifies the caseworker verbally, the provider agency must send written notification to the contract manager or caseworker or both, within five business days of the initial notification.

If the person delivering the meal reports to the provider any individual illnesses, potential threats to safety or observable changes in the person's condition, the provider must notify the caseworker about the report within 24 hours. The provider must also notify the caseworker within 24 hours whenever the meal is found uneaten or untouched.

4532.1 Waivers for Alternate Meal Delivery Methods

Revision 24-4; Effective Sept. 1, 2024

Home Delivered Meals (HDM) providers generally deliver five hot meals a week to each person. Occasional exceptions to this rule, such as the use of frozen, chilled or shelf-stable meals for emergency or inclement weather situations, and situations approved by the contract manager on a case-by-case basis, may be granted. HDM providers must submit a waiver request to the Texas Health and Human Services Commission (HHSC) contract manager if they determine that delivery of frozen or shelf-stable meals is required for certain people within the provider's contracted service area. Any waivers granted will be effective for a period not to exceed one fiscal year. The provider must not implement the waiver of the requirement for delivery of a hot meal five days a week before HHSC approves the waiver request.

Caseworkers play a vital role in the waiver process. They are expected to work closely enough with the contract manager to be aware of the delivery provisions of each HDM provider. Any inquiries by providers about the waiver must be referred to the contract manager.

4532.2 Service Plan Changes

Revision 25-4; Effective Sept. 1, 2025

The caseworker must revise the service plan within 14 calendar days of learning that the person needs an increase or decrease in units, or document why no changes are needed.

For an increase in units the begin date on Form 2101, Authorization for Community Care Services must be seven calendar days from the Form 2101 date unless an earlier date is negotiated.

For a decrease in units allow 12-day adverse action, review 2811, Effective Dates, Appendix IX, Notification Effective Date of Decision and Appendix XVIII, Time Calculation.

The caseworker sends Form 2065-A, Notification of Community Care Services notifying the person of the change. If the caseworker decides the change is not necessary, send Form 2065-A. Document the reason and related handbook reference.

4533 Suspension of Services

Revision 25-4; Effective Sept. 1, 2025

Refer to 26 Texas Administrative Code Section 281.33, Suspension of Services.

The provider must notify the caseworker on the day Home-Delivered Meals is suspended without the caseworker's authorization. The provider must suspend services in any of the following situations when the:

• person moves out of the geographical area served by the provider;
• person enters an institution;
• person requests that services be suspended or terminated;
• person dies; or
• caseworker directs the provider to suspend services.

Unless the interruption is the result of one of the above situations, the provider must obtain the caseworker's approval for service interruptions of more than two consecutive days.

When the person requests that services be suspended and specifies a date for services to resume, the provider is not required to notify the caseworker.

4533.1 Provider Changes

Revision 25-3; Effective June 1, 2025

Allow the person the freedom to choose and change providers without restriction in areas where there is more than one provider for Home Delivered Meals.

Within 14 calendar days of person’s request to transfer providers, coordinate with both providers the date the current provider will stop providing services and the date the new provider will begin services. Review 2723, Freedom of Choice.

4534 Termination of Services

Revision 24-4; Effective Sept. 1, 2024

The caseworker must send the provider authorization for community care services for Title XX services, indicating the date services are to be terminated.

Send a copy of Form 2065-A, Notification of Community Care Services, to the provider as notification of the termination and of the date the service will end. Review 2800, Procedures for Denying or Reducing Services for detailed information about service termination.

4610 Primary Home Care (PHC) and Community Attendant Services (CAS) Contracting

Revision 25-3; Effective June 1, 2025

Primary Home Care (PHC) and Community Attendant Services (CAS) provide in-home personal attendant services (PAS) to people eligible under Title XIX Medicaid or under Section 1929(b)(2)(B) of the Social Security Act, respectively. Both programs require that recipients have a need for help with personal care tasks. Providers delivering PAS must meet all the requirements in 26 Texas Administrative Code Section 277.11, Contracting Requirements.

Refer to 4400, Family Care Services, for information on the Title XX PHCP program.

4620 Personal Attendant Services Description

Revision 25-3; Effective June 1, 2025

Primary Home Care and Community Attendant Services provide non-technical attendant services to eligible people with medical conditions resulting in a functional limitation performing personal care. Attendants help people with activities of daily living, such as bathing, grooming, meal preparation and housekeeping. Attendants are trained and supervised by non-medical personnel.

4621 Allowable Tasks

Revision 26-2; Effective June 1, 2026

Personal attendant services (PAS) that may be delivered under CAS and PHC include the following tasks.

Personal care tasks related to the care of the person's physical well-being, including:

• Bathing:
  • drawing water in sink, basin or tub;
  • hauling or heating water;
  • laying out supplies;
  • assisting in or out of tub or shower;
  • sponge bathing and drying;
  • bed bathing and drying;
  • tub bathing and drying; and
  • providing standby assistance for safety.
• Dressing:
  • dressing the person;
  • undressing the person; and
  • laying out clothes.
• Meal preparation:
  • cooking a full meal;
  • warming up prepared food;
  • planning meals;
  • helping prepare meals; and
  • cutting person's food for eating.
• Feeding or eating:
  • spoon-feeding;
  • bottle-feeding;
  • assisting with using eating and drinking utensils and adaptive devices, not including tube feeding; and
  • providing standby assistance or encouragement.
• Exercise:
  • walking with the person.
• Grooming:
  • shaving;
  • brushing teeth;
  • shaving underarms and legs, upon request;
  • caring for nails; and
  • laying out supplies.
• Routine hair or skin care:
  • washing hair;
  • drying hair;
  • assisting with setting, rolling or braiding hair, not including styling, cutting or chemical processing of hair;
  • combing or brushing hair;
  • applying nonprescription lotion to skin;
  • washing hands and face;
  • applying makeup; and
  • laying out supplies.
• Assistance with self-administration of medication:
  • reminding person to take a medication at the prescribed time;
  • opening and closing a medication container;
  • pouring a predetermined quantity of liquid to be ingested;
  • returning a medication to the proper storage area;
  • assisting in reordering medications from the pharmacy; and
  • administration of any medication when the person has the cognitive ability to direct the administration of their medication and would self-administer if not for a functional limitation.
• Toileting:
  • changing diapers;
  • changing colostomy bag or emptying catheter bag;
  • assisting on or off bedpan;
  • assisting with use of a urinal;
  • assisting with feminine hygiene needs;
  • assisting with clothing during toileting;
  • assisting with toilet hygiene, including the use of toilet paper and washing hands;
  • changing external catheter;
  • preparing toileting supplies and equipment, not including preparing catheter equipment; and
  • providing standby assistance.
• Transfer:
  • non-ambulatory movement from one stationary position to another, not including carrying;
  • adjusting or changing the person's position in a bed or chair – positioning; and
  • assisting in rising from a sitting to a standing position.
• Ambulation:
  • assisting in positioning for use of a walking apparatus;
  • assisting with putting on and removing leg braces and prostheses for ambulation;
  • assisting with ambulation or using steps;
  • assisting with wheelchair ambulation; and
  • providing standby assistance.

Home management tasks that support the person's health and safety, including:

• Cleaning:
  • cleaning up after the person's personal care tasks;
  • emptying and cleaning the person's bedside commode;
  • cleaning the person's bathroom;
  • changing the person's bed linens and making the person's bed;
  • cleaning floor of living areas used by person;
  • dusting areas used by person;
  • carrying out the trash and setting out garbage for pick up;
  • cleaning stovetop and counters;
  • washing the person's dishes; and
  • cleaning refrigerator and stove.
• Laundry:
  • doing hand wash;
  • gathering and sorting;
  • loading and unloading machines in residence;
  • using laundromat machines;
  • hanging clothes to dry; and
  • folding and putting away clothes.
• Shopping:
  • preparing a shopping list;
  • going to the store and purchasing or picking up items;
  • picking up medication; and
  • storing the person's purchased items.
• Escort:
  • accompanying the person outside the home to support the person in living in the community;
  • arranging for transportation, not including direct person transportation;
  • accompanying the person to a clinic, doctor's office or location for medical diagnosis or treatment; and
  • waiting in the doctor's office or clinic with person if necessary because of person's condition or distance from home.

CCSE staff must document a specific need for escort. If escort for medical trips occurs at least once a month, time may be allocated. To find the weekly time allocation, divide the time by 4.33 to arrive at a weekly figure. If escort occurs more than once a week, include added documentation to explain why the person needs escort this often. Review Form 2060, Needs Assessment Questionnaire, Task and Hour Guide.

Since escort is always determined and entered on a weekly basis, use the following examples for escort services.

Example 1: A person has a doctor’s appointment every week for one hour with their chiropractor and needs another hour transportation time to get to and from the doctor’s office. The person needs two hours total escort weekly. Enter 120 minutes weekly for escort. 

Example 2: A person has one appointment a month with their radiologist. The person needs four hours total for their monthly appointment. Formula: four hours x 60 minutes = 240 minutes. 240 minutes ÷ 4.33 = 55.43 minutes per week which rounds up to 60 minutes per week.

Monthly minutes must be divided by 4.33 – weeks per month – to obtain a weekly amount of minutes needed.

Example 3: A person sees their cardiologist two hours, general practitioner three hours, chiropractor three hours and psychologist two hours every month. These are standing monthly appointments. Two hours + three hours + three hours + two hours = 10 hours monthly. 10 hours x 60 minutes = 600 minutes. 600 minutes ÷ 4.33 = 138.57 minutes per week, which arounds up to 140 minutes per week. Enter 140 minutes per week.

While the Service Authorization System Online (SASO) automatically rounds up in five-minute increments, services are allotted and delivered in 30-minute increments so the person will actually receive 150 minutes or 2½ hours a week.

Example 4: The person sees a therapist every other Friday – biweekly – for 2½ hours including travel time. 2½ hours x 60 minutes = 150 minutes. 150 minutes x 2.17 Fridays per month = 325.50 minutes total per month. 325.50 minutes per month ÷ 4.33 weeks per month = 75.17 minutes per week, which rounds up to 80 minutes. Enter 80 minutes per week.

Biweekly amounts must be multiplied by 2.17 to obtain a monthly amount, which can then be divided by 4.33 to obtain a weekly amount.

Example 5: The person was in a car accident and has a large need for escort. They see a chiropractor three times a week for one hour each time, a physical therapist three times a week for an hour each time, a psychiatrist biweekly for two hours, a pain management specialist biweekly for two hours, a general practitioner two hours per month and a cardiologist once a month for three hours.

In this example, no action is needed for the chiropractor and physical therapist as their times are already in the weekly amounts. The conversions needed apply to the biweekly and monthly visits, which need to be converted to weekly amounts and then all added together.

Weekly: 6 hours x 60 minutes = 360 minutes

Biweekly: 4 hours x 60 minutes x 2.17 = 520.80 ÷ 4.33 = 120.28 – per week

Monthly: 5 hours x 60 minutes = 300 minutes ÷ 4.33 = 69.28 – per week

360 + 120.28 + 69.28 = 549.56 minutes per week, which rounds to 550 minutes per week.

Escort may also include accompanying the person on nonmedical trips such as the grocery store, paying bills, pharmacy, hair stylist, barber or social events. No more time for escort for nonmedical trips is allocated to the person's service plan on Form 2060. The person may elect to receive escort in place of assistance with household or personal care on a day that best meets their needs. The time used to provide the escort task must not exceed the total time purchased for attendant care.

This service does not include the direct transportation of the person by the attendant. Transportation is available through the Medical Transportation Program (MTP). Contact the regional MTP manager about the person’s referral to this program.

Related Policy

Contracting to Provide Primary Home Care Services Handbook

4622 Excluded Services

Revision 25-3; Effective June 1, 2025

Services that must be provided by a person with professional or technical training may not be purchased through Title XIX personal attendant services. These excluded services include, but are not limited to:

• insertion and irrigation of catheters;
• irrigation of body cavities;
• application of sterile dressings involving prescription medications and aseptic techniques;
• tube feedings;
• injections;
• administration of medication; or
• any other skilled services identified by the Texas Health and Human Services Commission nurse.

Services that maintain an entire family or household, unless the entire household receives Community Care Services Eligibility services, are also excluded. Examples include:

• cleaning the floor and furniture in areas that the person does not occupy or use;
• preparing meals for the entire family or household;
• laundering clothing or bedding that the person does not use, for example, laundering clothing and bedding for the entire household rather than laundering only the person's clothing and bed linens; or

shopping for groceries or household items the person does not need for health and maintenance. Note: An attendant may shop for items the person needs and the rest of the household also uses.

4623 Personal Attendants

Revision 21-4; Effective December 1, 2021

The person's or provider's choice of attendants is not limited unless:

• CCSE staff specify a particular attendant should not be employed by the provider; or
• a supervisor, CCSE staff or regional nurse determines the attendant is not providing adequate care.

Personal attendant services tasks may be performed by an unlicensed person who is 18 or older and has demonstrated competency to perform the tasks assigned by the supervisor. Additionally, tasks may be performed by an unlicensed person who is:

• under 18 years old and a high school graduate; or
• enrolled in a vocational educational program and has demonstrated competency to perform the tasks assigned by the supervisor.

The attendant cannot be a legal or foster parent of a minor child who receives the service, or the service recipient's spouse. 

Related Policy 

Who Cannot Be Hired as the Paid Attendant, 2514

4624 Priority Status Determination

Revision 22-4; Effective Dec. 1, 2022

Evaluate the effect that going without certain critical purchased tasks would have on a recipient to determine priority status.

Establish priority status for each applicant or recipient based on the functional assessment. A recipient is considered to have priority status if the following criteria is met:

• The recipient is completely unable to perform one or more of the following activities without hands-on assistance from another person:
  • transferring into or out of bed, to a chair or on or off a toilet;
  • feeding;
  • getting to or using the toilet; or
  • preparing a meal.
• During a normally scheduled service shift, no one is available who is capable and willing to provide the needed assistance other than the attendant.
• There is a high likelihood the recipient’s health, safety, or well-being would be jeopardized if services are not provided on a single given shift.

A recipient with priority status may receive no more than 42 hours of service per week. 

A recipient without priority status may receive no more than 50 hours of service per week.

Related Policy 

Priority Status, 2540
Eligibility for CCSE Services, 3110
Age Limits, 3111
Resource Eligibility Criteria, 3200
Income Eligibility, 3300

4631 Residence

Revision 25-3; Effective June 1, 2025

To receive services, the person must live in a place other than:

• a hospital;
• a skilled nursing facility;
• an intermediate care facility;
• an assisted living facility;
• a foster care setting;
• a jail or prison;
• a state school;
• a state hospital; or
• any other setting where sources outside the primary home care program are available to provide personal care.

Title XIX personal attendant services (PAS) cannot be authorized if the person lives in a home licensed as a personal care home by the Texas Department of State Health Services. If the home is not a licensed personal care home, services may be authorized as follows:

• If three or fewer people live in the home, the proprietor can be the PAS attendant for the person(s) who live there. The person may not receive both PAS and Adult Foster Care.
• If the home provides only room and board to four or more people living in the home, it does not require licensure as a personal care home. PAS services can be authorized for people in this setting, but the proprietor, their agent or employee cannot be the attendant for people who live in the home. The caseworker must specify this on Form 2101, Authorization for Community Care Services.

Title XIX PAS services can be provided to a private pay applicant or person living in a residential care facility if they are contracted with HHSC or not, under the following conditions:

• The caseworker applies the unmet need policy on a task by task basis, not duplicating services.
• Facilities provide varying degrees of help. Tasks purchased should not be a task provided by the facility.
• The caseworker must closely monitor the case to determine if the person is receiving other services from the facility. Service plans must be adjusted to avoid duplication of services or tasks.

If the person begins receiving residential care (RC) through HHSC, the Title XIX PAS service is terminated effective by the date RC services begin.

Related Policy

26 Texas Administrative Code Section 271.81(b)

4632 Financial Eligibility

Revision 25-5; Effective Dec. 1, 2025 

To be eligible for PHC or CAS, the person must be eligible for Medicaid in a community setting or be eligible under the provisions of the Social Security Act, Section 1929(b)(2)(B).

Before referring the person to PHC, verify Medicaid eligibility for the month that financial and functional eligibility is determined.

To receive PHC services, a person must be receiving benefits that include full Medicaid eligibility. Caseworkers must consult the Texas Integrated Eligibility Redesign System (TIERS) to determine if an applicant or person is receiving full Medicaid benefits. Note: Residence outside an institution is also an eligibility standard. Institutional type programs will not be eligible for PHC, unless the person has been discharged from institution. Review 7110, TIERS Inquiries, and Appendix XIV, TIERS Type Program Chart, for a description of all TIERS type programs.

People get financial eligibility for CAS by applying to Medicaid for the Elderly and People with Disabilities. Confirm CAS eligibility by checking TIERS.

Review 2347, Texas Medicaid Estate Recovery Program (MERP), when processing CAS applications.

Related Policy

26 Texas Administrative Code Section 271.81(a)

4633 Functional Eligibility

Revision 26-1; Effective March 1, 2026

To be eligible for Primary Home Care (PHC) or Community Attendant Services (CAS), the person must meet the minimum functional need criteria set by HHSC.

Title XIX personal attendant services (PAS) eligibility only requires that a person need help with personal care. However, the provider is not allowed to provide services unless at least one personal task is authorized, scheduled and delivered by the provider.

Example: An applicant requests PHC and scores 30 on Form 2060, Needs Assessment Questionnaire, Task and Hour Guide. However, the only personal care task the person needs is meals service, which is provided by congregate meals. Therefore, PHC services cannot be approved.

A person must score at least 24 on Form 2060 and require at least six hours of service per week. A person who requires less than six hours of service per week may be eligible if the person:

• requires PHC or CAS to provide caregiver support;
• lives in the same household as another person who receives PHC, CAS or Family Care;
• receives one or more of the following services through HHSC or other resources:
  • congregate or home-delivered meals;
  • help with activities of daily living from a home health aide;
  • Day Activity and Health Services; or
  • Special Services to People with Disabilities in adult day care;
• receives aid-and-attendance benefits from Veterans Affairs; or
• is determined based on the functional assessment to be at high risk of institutionalization without PHC or CAS.

Review 4651, Assessing the Person’s Needs, for casework procedures involved in establishing functional need.

Related Policy

26 Texas Administrative Code Section 271.81(a)

4634 Practitioner's Statement of Medical Need

Revision 26-1; Effective March 1, 2026

The need for PHC and CAS must be documented by Form 3052, Practitioner's Statement of Medical Need. As part of the determination of eligibility for Title XIX PAS, the regional nurse must verify that the person has a medically related health problem that causes a functional limitation in performing personal care.

Review 4661, Receipt of the Practitioner's Statement of Medical Need, for procedures to determine medical need.

If a person had PHC or CAS services in the past and was denied for any reason or had a loss of Medicaid eligibility and Form 2101, Authorization for Community Care Services, was sent terminating services or transferring to FC, a new Form 3052 would be required.

Related Policy

26 Texas Administrative Code Section 271.81(a)

4640 Retroactive Payments

Revision 25-3; Effective June 1, 2025

Home and community support services agencies that provide personal attendant services (PAS) must be licensed by the Texas Health and Human Services Commission (HHSC) per state law. It is possible for a Medicaid-eligible person to begin receiving services before HHSC receives a referral for Primary Home Care (PHC). The information in 4641, Provider's Role and 4642 Caseworker’s Role, state the procedures caseworkers, regional nurses and providers must use when processing an application for retroactive payment.

4641 Provider's Role

Revision 25-3; Effective June 1, 2025

A provider who delivers attendant care services to a non-Medicaid person on a private pay basis risks losing revenue unless an agreement exists for the person to pay the provider if they are not determined eligible. A provider may bill non-Medicaid people for services delivered before the time the person is eligible for retroactive payment by the Texas Health and Human Services Commission (HHSC). However, federal requirements do not allow providers to bill Medicaid recipients for Medicaid reimbursable services.

26 Texas Administrative Code (TAC) Section 277.85(C)(1) states the provider agency may be reimbursed for services provided before the date a completed, signed, and dated copy of DHS' Application for Assistance Aged and Disabled form is received for:

• up to three months for a person who does not have Medicaid eligibility at the time of the request for retroactive payment; and
• an indefinite period for a person who is Medicaid eligible at the time of the request for retroactive payment.

The three-month prior period:

• applies to non-Medicaid people who apply for Primary Home Care (PHC) services using retroactive payment procedures; and
• does not apply to Medicaid recipients who request PHC services using retroactive payment procedures.

For Medicaid recipients, HHSC can reimburse a provider for a retroactive payment period beyond three months if the services are Medicaid reimbursable and the person was Medicaid eligible when the services were received. Medicaid recipients do not complete a written application Form H1200, Application for Assistance – Your Texas Benefits for retroactive or ongoing PHC services.

A request for retroactive payment can be made by the person, provider or interested party by contacting Community Care Services Eligibility (CCSE) intake staff. CCSE staff who receive requests for retroactive payment use current intake procedures for a routine request for in-home care services. The beginning date of services cannot be prior to the practitioner's signature date on Form 3052, Practitioner's Statement of Medical Need.

The provider agency must complete the pre-initiation activities described in 26 TAC Section 277.45 of this chapter relating to Pre-Initiation Activities.

(f)Intake referral - On the day that the provider agency completes the pre-initiation activities, the provider agency must contact the local HHSC office by phone. They must make an intake referral by providing HHSC information on the person to start the eligibility process. 
(g)Service initiation - The provider agency must not begin to provide services to the person before the date the provider agency completes the pre-initiation activities and processes the intake referral as described in subsections (e) and (f) of this section.

Within seven calendar days after the date the provider processes the intake referral, the provider must submit the written request for retroactive payment to the caseworker. The written request must include the:

• copy of the service plan;
• copy of Form 3052;
• retroactive payment information, including the:
  • name of the provider;
  • contact information for the person;
  • date services were started;
  • tasks provided to the person including both tasks allowed and not allowed by the PHC program;
  • actual service hours that were provided per week, including hours allotted to allowed tasks and tasks not allowed by the PHC program; and
  • cost per hour of service charged to the person.

If the provider billed the person for tasks that are not Medicaid reimbursable, the provider must inform the caseworker so they will know how many hours to deduct from the payment made by HHSC to the provider.

4642 Caseworker's Role

Revision 25-3; Effective June 1, 2025

The caseworker must respond to the request for services per the time frames in 2320, Caseworker Response, and make the home visit to assess the applicant for ongoing services.

The caseworker is not responsible for determining functional need during the retroactive period. Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, is completed to determine ongoing functional eligibility but does not affect eligibility for retroactive payments. Also, the caseworker does not apply the unmet need policy to the retroactive period. Review 2433, Determining Unmet Need in the Service Arrangement Column.

4643 Applicant Approved for Retroactive Payment and Continued Services

Revision 25-3; Effective June 1, 2025

The Texas Health and Human Services Commission (HHSC) will only reimburse the provider for tasks, hours and costs within the scope of the Primary Home Care (PHC) program If the applicant is or was Medicaid eligible at service initiation. If the applicant is eligible for the retroactive payment period and for continued PHC services, the caseworker must verify that the service plan developed by the provider contains the following information:

• person is receiving at least one personal care task and if there are no personal care tasks, the provider will not be reimbursed for services;
• total amount of weekly service hours;
• the total amount of weekly services hours are within the maximum weekly hours 50 allowed in the PHC program;
• tasks provided are the type covered under the PHC program; and
• cost per hour of service is equal to the non-priority rate in the PHC program. Note: Provider agencies will not determine priority status or be reimbursed at the higher priority status rate for the retroactive payment period.

Determine the amount of reimbursement the applicant is eligible to receive from the provider by multiplying the cost per hour of service found in the service plan developed by the provider times the total amount of hours of approved service provided to the applicant. Include this amount on Form 2065-A, Notification of Community Care Services, to advise the applicant and the provider of the dollar amount of retroactive payment the applicant should receive from the provider.

Note: Because the person is receiving services up the service initiation date for continued PHC services, the caseworker may not know the last day services were provided during the retroactive period. The reimbursement amount may vary from the actual amount depending on if the applicant paid in full or has not paid the provider for the most recent service provided during the retroactive period.

The provider will not be reimbursed for a retroactive payment period if:

• the applicant did not receive any personal care tasks from the provider;
• none of the tasks provided by the provider were within the scope of the program. Example: the person received transportation, direct administration of medications or protective supervision assistance; or
• the applicant is determined ineligible for retroactive payment by HHSC.

The provider will not be reimbursed for amounts higher than the HHSC limits when the:

• service plan includes more than the maximum weekly hours allowed in PHC; or
• cost per hour of service is more than the non-priority rate.

The caseworker must deduct time for any task(s) that cannot be purchased as part of PHC service from the total hours of services provided by the provider. This is to determine how many hours at the non-priority status rate HHSC will reimburse the provider. If more than 50 hours per week were provided, the time for the non-allowable tasks should be deducted first and then the additional hours deducted to be within the 50 hour per week limit.

Send the provider a copy of the same Form 2065-A sent to the applicant to advise the provider of the amount to reimburse the applicant. Multiply the total service hours the applicant received by the cost per hour of services reported in the provider's service plan. Note: The dollar amounts used in the examples are fictitious. The current PHC rates may be verified at Long-term Services & Supports.

Example 1:

A provider documents in the service plan that an applicant received 52 hours of service at $12.00 an hour for one week of the retroactive period. Of the total 52 service hours reported to date, three hours were for transportation. Calculate the amount the provider is paid using the following example as a guide.

52 hours minus 3 hours — deduct 3 hours since transportation is not an allowable task in PHC = 49 hours

49 hours x $9.61 — the non-priority participating rate in PHC = $470.89

$470.89 is the amount HHSC will pay the provider.

Document 49 hours in Item 18, Units, on Form 2101, Authorization for Community Care Services, and send it to the provider.

49 hours x $12.00 an hour estimated private-pay rate = $588.00. This is the amount of Medicaid-reimbursable tasks the provider must reimburse the person.

Document $588.00 on Form 2065-A and send it to the applicant to advise them of the amount they should be reimbursed from the provider. Send a copy of Form 2065-A to the provider to advise the provider of the amount it must reimburse the person. The provider can privately bill the person for three hours of services determined by the caseworker not to be Medicaid-reimbursable tasks.

Example 2:

A provider documents in the service plan that an applicant received 55 hours of service at $10.00 an hour for one week of the retroactive period. All the 55 service hours were performed on Medicaid-reimbursable tasks. Calculate the amount the provider is paid using the following example as a guide.

55 hours minus 5 hours — deduct five hours which exceed the weekly limit allowed in PHC = 50 hours

50 hours x $9.61 = $480.50

$480.50 is the amount HHSC will pay the provider.

Document 50 hours in Item 18, Units, on Form 2101 and send to the provider.

50 hours x $10.00 an hour = $500.00. This is the amount of Medicaid-reimbursable tasks the provider must reimburse the person.

Document $500.00 on Form 2065-A and send it to the applicant to advise them of the amount they should be reimbursed from the provider. Send a copy of Form 2065-A to the provider to advise the provider of the amount it must reimburse the applicant.

Example 3:

A provider documents in the service plan that an applicant received 55 hours of service at $12.00 an hour for one week of the retroactive period. Of the total of 55 service hours provided, three hours were for transportation. Calculate the amount the provider is paid using the following example as a guide.

55 hours minus 3 hours for transportation — a non-Medicaid reimbursable task = 52 hours

52 hours minus 2 hours — deduct two hours which exceed the weekly limit allowed in PHC = 50 hours

50 hours × $9.61 = $480.50

$480.50 is the amount HHSC will pay the provider.

Document 50 hours in Item 18, Units, on Form 2101 and send it to the provider. Send the usual initial PHC packet to the provider for the continued service period.

50 hours x $12.00 an hour = $600.00. This is the amount of Medicaid-reimbursable tasks the provider must reimburse the applicant.

Document $600.00 on Form 2065-A and send it to the applicant to advise them of the amount they should be reimbursed from the provider. Send a copy of Form 2065-A to the provider to advise the provider of the amount it must reimburse the person. The provider can privately bill the person for the three hours for transportation since this is not a Medicaid-reimbursable task.

If a provider provides service to a person during a retroactive period where all tasks, hours, costs are all within the scope of the PHC program, then the dollar amount due the person and the provider will be the same.

Example: A provider documents in the service plan that the person received 30 hours of allowable household and at least one personal care task per week and charged the person $9.61 an hour non-priority participating PHC rate to provide the attendant care. Calculate 30 hours x $9.61 = $288.30. This is the amount HHSC pays the provider and is the same amount refunded by the provider to the applicant. In this example, advise both the provider and the applicant the same amount, using Form 2065-A.

Send the provider Form 2101 for the retroactive payment period with an end date the day before the beginning of the continued PHC services. Send a second Form 2101 authorizing ongoing services with the complete initial PHC packet.

4644 Applicant Approved for Retroactive Payment and Denied Continued Services by the Caseworker

Revision 25-3; Effective June 1, 2025

The caseworker must call and notify the provider of the last day of the retroactive period and the ineligibility for ongoing services if the applicant is eligible for the retroactive period but is not financially or functionally eligible for continued Primary Home Care (PHC) services. Document the phone call in the comments section of Form 2101, Authorization for Community Care Services, for the retroactive period.

The caseworker must verify the following conditions are present in the service plan developed by the provider:

• applicant is receiving at least one personal care task;
• total amount of weekly service hours are within the maximum weekly hours 50 allowed in the PHC program; and
• the tasks provided are covered within the PHC program.

The provider is not reimbursed if no personal care task(s) were provided. The amount of reimbursement is reduced if the:

• service plan includes more than the 50 weekly maximum hours allowed in PHC;
• tasks provided are not the type of tasks covered by the PHC program; or
• cost per hour of service the provider billed the applicant is more than the Texas Health and Human Services Commission non-priority rate.

Within two business days of the decision of ongoing ineligibility, the caseworker sends the applicant and the provider Form 2065-A, Notification of Community Care Services, including:

• effective date of denial of continued services; and
• amount the provider should reimburse the applicant.

The caseworker must complete and send Form 2101 to the provider for the retroactive payment period. Use the Form 2101 instructions to complete the items for the retroactive period with the following exceptions:

• Item 4 — Begin date is obtained from the applicant's service plan which was developed by the provider. The begin date cannot be before the practitioner's signature date on Form 3052, Practitioner's Statement of Medical Need.
• Item 5 — End date is the date the caseworker determines the applicant ineligible for continued PHC services. The End date on Form 2101 must match the:
  • effective date of denial on Form 2065-A; and
  • verbal termination date for the retroactive period.
• Item 18 — Enter the amount of service hours minus any disallowed tasks, cost and hours for services that are not Medicaid reimbursable.
• Item 31 — Last name of Doctor of Medicine or Doctor of Osteopathic Medicine (MD or DO) = RETRO PAS
• Item 33 — MD or DO License Number
• Item 34 — Date of Orders

4645 Special Procedures for Community Attendant Services (CAS)

Revision 25-2; Effective March 31, 2025

Providers must be aware of the risk of losing revenue if attendant care services are delivered to a non-Medicaid person. If the applicant is determined ineligible, retroactive payment will not be made by the Texas Health and Human Services Commission (HHSC).

The caseworker proceeds with the referral to Medicaid for the Elderly and People with Disabilities (MEPD) on receipt of Form H1200, Application for Assistance – Your Texas Benefits, following the CAS referral procedures.

When the eligibility decision is received from MEPD and the applicant is determined eligible, the caseworker sends the regional nurse a copy of the pre-assessment packet from the provider and Form 3052, Practitioner's Statement of Medical Need, along with a pending Form 2101, Authorization for Community Care Services, for the retroactive period. The caseworker enters Retroactive Payment Applicant in the comments section on Form 2101. The regional nurse may authorize services effective the start date of service delivery as long as it is within the three months prior to the medical effective date established by MEPD, and other conditions are met. The regional nurse also completes a second Form 2101 for ongoing services if the applicant is eligible for ongoing CAS. Review 4662.1, Authorization for Routine Referrals, for procedures for ongoing authorization. The regional nurse sends a copy of Form 2101 for the retroactive period and a copy of Form 2101 for ongoing services to the provider and the caseworker.

Within two business days of receipt of Form 2101, the caseworker sends the applicant and the provider Form 2065-A, Notification of Community Care Services, for the retroactive period which includes the:

• effective dates of the retroactive period;
• total weekly hours of service approved; and
• amount to be reimbursed to the applicant.

The caseworker sends a second Form 2065-A to the applicant advising of ongoing services, including the effective date and the total weekly hours.

4646 CAS Applicant Determined Ineligible by MEPD Staff

Revision 17-1; Effective March 15, 2017

If the Community Attendant Services (CAS) applicant is determined ineligible by Medicaid for the Elderly and People with Disabilities (MEPD) staff, the case worker must:

• immediately notify the provider that the applicant is not Medicaid eligible, advising of the date of Medicaid denial; and
• send the applicant and provider Form 2065-A, Notification of Community Care Services, advising the denial for retroactive payment and continued services.

Note: The provider will not be reimbursed for retroactive services by the Texas Health and Human Services Commission and the provider does not have to reimburse the applicant for privately paid services.

4647 Notifications

Revision 17-1; Effective March 15, 2017

For all decisions on retroactive payments, both the applicant and the provider must be sent Form 2065-A, Notification of Community Care Services. The applicant must also be notified of eligibility or ineligibility for ongoing services on Form 2065-A. The provider is sent Form 2101, Authorization for Community Care Services, authorizing the retroactive services and Form 2101 for ongoing services, if the applicant is eligible.

4647.1 Notifications to Providers

Revision 25-3; Effective June 1, 2025

Send the provider:

• a copy of Form 2065-A, Notification of Community Care Services for all decisions on retroactive payments.
• Form 2101, Authorization for Community Care Services, for any service authorizations.

If, during the retroactive determination process for Primary Home Care the applicant is determined ineligible for continued services, the caseworker must call the provider immediately to advise of the applicant's ineligibility. The caseworker documents the phone call in the comments section of Form 2101, authorizing the retroactive period.

4647.2 Notifications to Applicants

Revision 17-1; Effective March 15, 2017

Applicants must be notified of all decisions on Form 2065-A, Notification of Community Care Services, within two business days of the date of the decision. If the applicant is determined eligible for retroactive and continued services, send two Form 2065-As. Form 2065-A for the retroactive period must contain the effective dates, type and amount of service authorized and the amount of reimbursement the applicant should receive for the services the provider delivered during the retroactive period. The second Form 2065-A advises the applicant of the eligibility for ongoing services, including the effective date, type and amount of service authorized.

If the applicant is denied for retroactive and continued services, document in the comments section of Form 2065-A that the applicant is ineligible for continued Primary Home Care or Community Attendant Services and is not eligible for retroactive payments from the provider for the months of the retroactive period (list the actual months). Retroactive payment applicants who appeal because payment was denied by the Texas Health and Human Services Commission are not entitled to payment for continued services pending outcome of the appeal.

4648 Reimbursement

Revision 25-2; Effective March 31, 2025

26 Texas Administrative Code Section 277.85(i), Charges to people who receive services.

1. The provider agency may charge a person for services that the provider agency intends to request retroactive payment, unless the person is Medicaid eligible.
2. The provider agency must reimburse the entire amount of all payments made by the person to the provider agency for eligible services, even if those payments exceed the amount HHSC will reimburse for the services, if HHSC determines that the person is eligible for the Primary Home Care.

If the Texas Health and Human Services Commission determines the applicant is eligible for Primary Home Care or Community Attendant Services, the provider must reimburse the entire amount of all payments made to the provider for eligible services during the three months before eligibility, if those payments exceeded the amount the provider will be reimbursed for those services.

If an applicant has a question or does not agree with the amount of reimbursement from the provider, it is up to the applicant, caregiver, authorized representative or applicant's family to advise the caseworker of any discrepancies between the:

• amount of money the caseworker advised that the applicant would receive; and
• actual amount received from the provider.

Final resolution of any disagreements between the provider, person or caseworker over the amount of reimbursement due the person is resolved by the caseworker's supervisor. The supervisor may consult appropriate regional support staff to reach a final decision involving reimbursement disagreements. Note: The provider must reimburse the person within seven calendar days of receiving payment from HHSC.

4650 Service Planning

Revision 25-3; Effective June 1, 2025

The caseworker is responsible for all aspects of service planning for Primary Home Care (PHC), including:

• determining the applicant's eligibility for services, described in 4632, Financial Eligibility, 4633, Functional Eligibility and 4634, Practitioner’s Statement of Medical Need;
• developing a service plan based on the applicant's unmet need for service, described in 2433, Determining Unmet Need in the Service Arrangement Column;
• authorizing services and referral to a provider, described in 4660, Service Authorization; and
• providing ongoing case management for the person.

The caseworker follows the procedures for initial intakes in 2300, Responding to Requests for Service. The initial home visit and functional assessment are completed per 2400, Assessment Process. Note on the worksheet of Form 2059, Summary of Client's Need for Service, the applicant's reported medical diagnosis and functional limitations. If the person reports only a diagnosis of mental health, intellectual disability (ID) or intellectual and developmental disability (IDD), discuss that they may not meet the medical eligibility criterion for PHC. Advise the applicant that the provider contacts their medical practitioner for more medical information. In developing the service plan, ensure that the applicant needs at least one personal care task.

4651 Assessing the Person's Needs

Revision 25-3; Effective June 1, 2025

Conduct a functional assessment of the applicant, described in 2430, Functional Assessment in a face to face interview with the person. The caseworker may consult the Texas Health and Human Services Commission (HHSC) nurse about any issues that:

• may impact individual health and safety; or
• bring medical and functional eligibility into question.

If, during the process of developing the service plan, it is determined that a particular person should not be employed as the person's attendant, the caseworker documents this information on Form 2101, Authorization for Community Care Services. Review 2514, Who Cannot Be Hired as the Paid Attendant, for additional information.

Review the service plan and explain the services to the person. Let them know the number of hours and number of days services are to be delivered and the tasks they are authorized to receive. Inform the person that to continue to qualify for services, they must need at least one personal care task. If the person does not need a personal care task, Title XIX personal attendant services (PAS) cannot be authorized. The person must also need at least six hours of services per week, unless they meet one of the criteria listed in 4633, Functional Eligibility. Assess the person for Family Care Services if the criteria for Title XIX PAS are not met.

Give Form 2307, Rights and Responsibilities, and Attachment 2307-A, Family Care, Community Attendant Services and Primary Home Care Rights and Responsibilities, to all applicants. Explain that the caseworker must approve changes in the service plan. Also, inform the person that they may select another provider if they are dissatisfied with the services or attendant providing the services.

If the Primary Home Care applicant meets all eligibility criteria, send a referral packet to the provider within five business days from the face to face interview. This referral will prompt the provider to begin pre-initiation activities.

If the Community Attendant Services applicant meets all functional eligibility criteria, send the Application for Assistance form to Medicaid for the Elderly and People with Disabilities for the financial determination.

4651.1 Service Delivery Outside the Home

Revision 25-2; Effective March 31, 2025

Services may be authorized to be delivered in locations other than the person's home.

For service delivery outside the person’s home but within a provider agency’s contracted service delivery area:

• The provider agency may develop a service plan that includes services regularly delivered at a location other than the person’s home. The service plan must not exceed the weekly hours authorized on Form 2101, Authorization for Community Care Services.
• The provider agency may deliver services outside the person’s home when the service plan does not include the regular delivery of such services.

The provider agency:

• may deliver services outside the person’s home only if the person requests such services;
• is not required to pay for expenses incurred because of an attendant delivering services outside the person’s home;
• must make a reasonable effort to deliver services at a location other than the person’s home when requested by the person;
• maintains written justification if the person’s request was not granted; and
• documents in the person’s record:
  • each instance when the person requested services at a location other than the home;
  • if the person’s request was granted;
  • what services were provided; and
  • where the services were delivered.

26 Texas Administrative Code Section 277.63, Service Delivery, provides the rules for Home and Community Support Services (HCSS) agencies to deliver services outside the home. The provider may develop a service plan that includes services regularly delivered at a location other than the person's home or may deliver services at an alternate location at the person's request. Review 2522, Service Delivery in Alternate Locations, for more caseworker procedures.

If a person is temporarily staying at a location outside the provider’s contacted service delivery area, but within Texas, a provider may accept or decline the request. If the provider accepts a person’s request the provider may provide services to the person during a period of no more than 60 consecutive days. If a person intends to remain outside a provider’s contacted service delivery area for a period of more than 60 consecutive days, the caseworker transfers the person to a provider selected by the person that has a contract in the area where the person has been receiving services.

Caseworkers should pay particular attention to this policy if they have people with disabilities who are working or attending school and need help in the workplace or school. The Social Security Administration has several programs to help people with disabilities with employment.

Additionally, people enrolled in the Medicaid Buy-In program will be working and may require service delivery in alternate locations.

While services may be delivered outside the home, only allowable tasks may be authorized. The provider is not required to pay for expenses incurred by attendants delivering services outside the home. Hours authorized are based solely on services that could be delivered in the home.

The caseworker must send Form 2067, Case Information, to the provider with information about the person's request for services in an alternate location and work with the person and provider to arrange the services that will meet the persons needs within the scope of the program.

4652 Types of Referrals

Revision 25-3; Effective June 1, 2025

There are two methods of referral:

• For expedited referrals, the caseworker makes the referral by verbal notice and on Form 2101, Authorization for Community Care Services.
• For routine referrals, the caseworker makes the referral on Form 2101.

Review Appendix IV, Workflow and Time Frames, for procedures for the different types of referrals.

4652.1 Routine Referrals for Primary Home Care

Revision 25-3; Effective June 1, 2025

For routine Primary Home Care (PHC) referrals, complete the following within five business days after the home visit:

• enter the assessment information in the Service Authorization System Online (SASO); and
• send a referral packet to the provider.

The referral packet must include:

• a cover sheet;
• the Long-term Care Services Intake System (NTK) generated Form 2110, Community Care Intake; and
• a copy of the following SASO generated forms:
  • Form 2059, Summary of Client's Need for Service;
  • Provider Referral Supplement;
  • Form 2060, Needs Assessment Questionnaire and Task/Hour Guide;
  • Task/Hour Guide; and
  • referral Form 2101, Authorization for Community Care Services.

The referral packet notifies the provider to begin pre-initiation activities.

Refer PHC applicants that are mandatory STAR+PLUS members to the enrollment broker.

Related Policy

Requests for Services in STAR+PLUS Areas, 2221
Content of Referral Packets, Appendix XIII

4652.2 Expedited Referrals for Primary Home Care

Revision 25-3; Effective June 1, 2025

The person’s need for services, based on the caseworker's judgment, might require facilitating delivery of services. The caseworker considers the following to weigh the need for an expedited referral:

• What was the person’s assigned intake priority? In most situations, cases that require an expedited response to a request for services also require an expedited referral.
• Is the person being authorized as having priority status? If so, that may indicate a need for an expedited referral.
• Could a delay in starting services constitute a threat to the person’s health, safety or well-being? If so, an expedited referral may be needed.

The following is the expedited referral process.

The caseworker:

• Makes a verbal request by the next business day from the home visit that immediately begins pre-initiation activities.
• Negotiates a date for the completion of pre-initiation activities, which must be less than 14 calendar days.
• Follows up the verbal request by sending a referral packet. Including Form 2101, Authorization for Community Care Services, to the provider noting the negotiated completion date in the comments section.

The regional nurse:

• Negotiates a start of care date with the provider upon notification of a completed practitioner's statement. This must be in less than 14 calendar days.
• Authorizes services in the Service Authorization System by the fifth business day after a start date has been negotiated.

The provider may only call the regional nurse to provide information from Form 3052, Practitioner's Statement of Medical Need, and negotiate a start-of-care date in the case of an expedited referral. The start of care for the expedited referral must be within the 14-day time frame for a routine referral and cannot be before the date the practitioner signed Form 3052. The provider must send the regional nurse Form 3052 within seven business days.

4652.3 Initial Referrals for Community Attendant Services

Revision 25-3; Effective June 1, 2025

Complete the following within seven business days after receiving the financial eligibility determination for CAS referrals:

• enter the assessment information in the Service Authorization System Online  (SASO); and
• send the provider a referral packet.

The referral packet must include:

• a cover sheet;
• the Long-term Care Services Intake System (NTK) generated Form 2110, Community Care Intake; and
• a copy of the following SASO generated forms:
  • Form 2059, Summary of Client's Need for Service;
  • Provider Referral Supplement;
  • Form 2060, Needs Assessment Questionnaire and Task/Hour Guide;
  • Task/Hour Guide; and
  • referral Form 2101, Authorization for Community Care Services.

Do not send a copy of the referral Form 2101 to the regional nurse on initial CAS cases. Send the referral packet to the provider. It is the provider's responsibility to send the required documents, including Form 3052, Practitioner's Statement of Medical Need, to the regional nurse.

Note: Providers are requested to send Form 2101 with Form 3052 as a courtesy to help with applicant identification, but this is not required.

Track the CAS referral. If the authorization Form 2101 is not received from the regional nurse within 30 calendar days after sending the referral Form 2101 to the provider, check with the regional nurse to check if the referral was received from the provider. If not, contact the provider and request Form 3052 be sent to the regional nurse.  Document all contacts in the case record.

Related Policy

Screening for Primary Home Care and Community Attendant Services, 2342
Workflow and Time Frames, Appendix IV
Content of Referral Packets, Appendix XIII

4652.4 CAS Applicants Requiring Immediate Service Delivery

Revision 24-4; Effective Sept. 1, 2024

While a Community Attendant Services (CAS) applicant's financial eligibility is pending, the caseworker may refer the person to Family Care (FC). Unless new intakes are being placed on the interest list by the region, a referral to FC is mandatory if the person:

• had an intake priority of immediate or expedited; or
• has a health condition requiring immediate service delivery to ensure their health and safety.

4653 Referral to the Provider

Revision 25-3; Effective June 1, 2025

Send the referral packet to the provider selected by the applicant or recipient. The referral packet must contain adequate information for the provider to develop the service plan based on the assessment.

The referral packet must include:

• a cover sheet;
• Form 2110, Community Care Intake; and
• a copy of the following Service Authorization System Online  (SASO) generated forms:
  • Form 2059, Summary of Client’s Need for Service;
  • Provider Referral Supplement;
  • Form 2060, Needs Assessment Questionnaire and Task/Hour Guide;
  • Task/Hour Guide; and
  • referral Form 2101, Authorization for Community Care Services.

All Form 2101 referrals to the provider, both initial and ongoing, must include the:

• authorized tasks;
• total number of authorized hours;
• number of days the applicant or recipient requests services be delivered; and
• relationship and name of any person designated as do not hire.

Document any of the following information in the comments section of the Form 2101:

• any special needs of the applicant or recipient that require a specific schedule and the reason;

  Example: <Name of person> is diabetic and requires a specific eating schedule, or <Name of person> requires service delivery in the afternoon due to a sleeping condition.

• the number of service days requested by the applicant or recipient based on the Form 2060;

Example: <Name of person> requests a five-day plan.

• the relationship and name of any person(s) designated as do not hire.
• Example: Do not hire <spouse>, <name of spouse>, for any tasks or do not hire <daughter>, <name of daughter>, for shopping.

Related Policy

Who Cannot Be Hired as the Paid Attendant, 2514 
Service Authorizations, 2620 
Referrals to the Provider, 2630 
Contents of Referral Packets, Appendix XIII

4654 Pre-Initiation Activities

Revision 25-3; Effective June 1, 2025

The provider begins pre-initiation activities once prompted by the receipt of the referral packet. This includes Form 2101, Authorization for Community Care Services.

Providers must complete pre-initiation activities:

• for routine referrals, within 14 calendar days of the referral date or the date the provider receives Form 2101, whichever is later.
• for expedited referrals, by the date negotiated between the caseworker and provider.

The provider supervisor must develop a service delivery plan on a single document that records pre-initiation activities including the following:

• the tasks the person is authorized to receive;
• the total weekly hours of service HHSC authorizes the person to receive; and
• certain time periods for the delivery of specified tasks, based on a person’s needs.

The provider must get a complete practitioner's statement and submit for HHSC's review, as described in 26 TAC Section 277.47, relating to Medical Need Determination. This does not apply to Family Care services. For routine referrals, the provider must:

• send a copy of the practitioner's statement to HHSC by facsimile or secured email; or
• mail a copy of the practitioner's statement to HHSC.

For expedited referrals:

• HHSC may send the authorization for community services form pending receipt of the practitioner's statement. This is if the provider notifies HHSC that they received a complete practitioner’s statement that documents the cause of the person’s functional impairment is the person’s medical condition.
• The provider must send the complete practitioner's statement to HHSC within seven business days of service initiation.
• If a complete practitioner's statement is not sent to HHSC within seven business days of service initiation, the provider is not entitled to payment from HHSC until the date HHSC receives the completed practitioner's statement. In this instance, HHSC will change the service initiation date to the date HHSC receives the completed practitioner's statement.
• The signature date of the practitioner must be on or before the negotiated start-of-care date.

Related Policy

26 Texas Administrative Code (TAC) Section 277.45 (c)(1-2)

4654.1 Delays in Pre-Initiation Activities

Revision 25-3; Effective June 1, 2025

The provider must complete the pre-initiation activities within the required time frames found in 4654, Pre-Initiation Activities, or document the reason(s) for a delay.

• A provider may delay meeting the due dates only for reasons beyond its control, such as natural or other disasters. The provider must continue efforts to complete pre-initiation activities and set a date, if possible, for completion of pre-initiation activities.
• The provider must document any failure to complete the pre-initiation activities for routine referrals by the due date, including:
  • the reason for the delay, which must be beyond the provider's control;
  • either the date the provider anticipates it will complete the pre-initiation activities or specific reasons why the provider cannot anticipate a completion date; and
  • a description of the provider's ongoing efforts to complete pre-initiation activities.
• The provider must notify the caseworker of any failure to complete the pre-initiation activities for expedited referrals before the negotiated date for completion of pre-initiation activities. The caseworker may refer the person to another provider.

4655 Initial Service Delivery Plan Changes

Revision 25-3; Effective June 1, 2025

The provider must notify the caseworker of a variance in the service delivery plan when the initial service delivery plan developed by the provider:

• has more hours than authorized on the authorization for community care services form; or
• has no personal care services, except for Family Care services.

After completing pre-initiation activities, if the provider does not agree with the service plan on Form 2101, Authorization for Community Care Services, the provider must send a notice to the caseworker explaining why changes are needed in the initial service plan.

Upon receipt of the written notification, the caseworker must contact the person within two business days to review the service plan and resolve the reported request for a change in tasks or hours. If the person consents to the initial service plan developed by the caseworker, the caseworker sends the provider Form 2067, Case Information, advising that the person is in agreement with the developed service plan. Review and update Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, if the person states that a change is needed. Include the changes on Form 2101 to the provider. Services must be authorized within five business days of receipt of the practitioner's statement. If a notification is received after services are authorized, process as an interim change. Review 4673, Interim Service Plan Changes.

If the person refuses all personal care tasks on the service plan, advise them that they will not be eligible for Primary Home Care or Community Attendant Services. Transfer the person to Family Care or place on the Family Care Interest List. Review 2720, Interim Changes, for more service plan changes guidelines.

4660 Service Authorization

Revision 17-1; Effective March 15, 2017

4661 Receipt of the Practitioner's Statement of Medical Need

Revision 24-2; Effective June 1, 2024

The provider must submit Form 3052, Practitioner's Statement of Medical Need to the Texas Health and Human Services Commission (HHSC) regional nurse before services can be authorized. A copy of the form must be retained in the case record.

4661.1 Review of the Practitioner's Statement

Revision 25-2; Effective March 31, 2025

The regional nurse reviews the practitioner’s statement to ensure the following:

• the practitioner completes the Statement of Medical Need to certify the applicant’s medical need resulting in a functional limitation;
• at least one functional limitation related to a diagnosis is checked;
• the form is complete with no missing information;
• the practitioner signed the form and the signature date is not before the intake date on Form 2110, Community Care Intake;
• the practitioner's license number and National Provider Identifier (NPI) is on the form; and
• the practitioner's contact information is on the form.

Note: The practitioner's name, phone number, license number and date of order must be entered in Service Authorization System Online (SASO).

Accept the practitioner's certification that the applicant has an acceptable medical diagnosis when the Statement of Medical Need on Form 3052, Practitioner's Statement of Medical Need, is complete. The practitioner must check at least one functional limitation related to the diagnosis(es). Accept that the practitioner has checked an appropriate functional limitation.

People with a diagnosis(es) of mental illness, intellectual disability (ID) or intellectual and developmental disability (IDD) only are not considered to have established medical need based only on those diagnoses. But, a medical need may be established through a related diagnosis that results in a functional limitation.

In this situation, the practitioner will not sign the Statement of Medical Need on Form 3052. The provider must notify HHSC that a signed Form 3052 will not be sent.

When completing the initial assessment and the applicant or family states the only diagnosis is mental illness, ID or IDD, consult with the regional nurse before making the referral for PHC or CAS. If it is clear at the time of the initial assessment there is no related medical diagnosis or if a signed Form 3052 cannot be obtained, place the applicant on the Family Care interest list. If funds are available, assess the applicant for Family Care services.

4661.2 Required Corrections

Revision 25-3; Effective June 1, 2025

The regional nurse reviews the practitioner's statement within two business days of receipt in an HHSC office. Determine if all information is correct or if it requires correction. If correction is required, act the same day. Depending on the type of error, return the practitioner's statement to the provider for correction or get the information by phone and request faxed confirmation when necessary.

Get the information by phone when:

• Form 3052, Practitioner’s Statement of Medical Need does not include the credential listed below, of the medical practitioner who signed the form:
  • MD for Doctor of Medicine
  • APN for Advanced Practice Nurse
  • DO for Doctor of Osteopathic Medicine
  • PA for Physician Assistant.
• Form 3052 does not include the license number or the National Provider Identifier (NPI) number of the practitioner who signed it.

The provider must fax an updated copy of Form 3052 when:

• the provider or financial management services agency (FSMA) did not complete Part II stating that the practitioner who signed the order is not excluded from participation in Medicare or Medicaid;
• the functional limitation is not checked;
• the practitioner's signature is not on Form 3052;
• the practitioner's signature date is missing or illegible;
• the provider's stamped date is used instead of the practitioner's date on Form 3052, which does not include the provider’s name, abbreviated name or initials;
• if the practitioner entered 99 months as an end date for temporary medical need; or
• more information is needed to authorize services.

Allow five business days for the provider to complete all corrections. If appropriate, expedited procedures may be used to refer the person to another provider.

Form 3052 does not require correction for missing medical diagnosis if the functional limitation has been checked.

4661.3 Closing Initial Referrals for Delays in Securing a Signed Practitioner’s Statement

Revision 25-3; Effective June 1, 2025

The caseworker may close the initial referral for services within 90 calendar days from the date of the initial Form 2101, Authorization for Community Care Services when contacts from the program provider and caseworker cannot get a signed practitioner’s statement.

The caseworker continues to monitor the initial referral for up to 90 more calendar days when the person or provider agency indicates to the caseworker that an appointment was made with an alternative physician to get the practitioner’s statement. The caseworker closes the referral by sending Form 2065-A, Notification of Community Care Services, to the applicant if the physician’s statement was not obtained following the second 90 calendar day extension period.

The caseworker will place the person on the Family Care interest list. They must advise Medicaid for the Elderly and People with Disabilities (MEPD) that the applicant was not approved for CAS. In this circumstance, the caseworker must send Form H1746-A, MEPD Referral Cover Sheet, stating the applicant has not met the functional eligibility requirements.

4662 Authorization of Services

Revision 17-1; Effective March 15, 2017

4662.1 Authorization for Routine Referrals

Revision 25-2; Effective March 31, 2025

For Community Attendant Services (CAS) and Primary Home Care (PHC), the Texas Health and Human Services Commission (HHSC) regional nurse must:

• enter the information into the Service Authorization System Online (SASO); and
• send authorization Form 2101, Authorization for Community Care Services to the provider.

Do this within five business days of receipt of the completed Form 3052, Practitioner’s Statement of Medical Need. The time frame starts when this form is received in an HHSC office. The form must be date stamped. The Begin Date, item 4 on Form 2101, is the same as the Mail Date, on item 1 of Form 2101. The regional nurse sends Form 3052 by electronic scan to the caseworker for retention in the person’s case record. The caseworker must file the form in the case record and retain the form per established form retention schedules.

If the region elects to have the regional nurse notify the caseworker by email, the nurse must include the person’s name, identification number, type of case action such as initial or annual recertification, and date the authorization in the email. The unit supervisor and other appointed HHSC staff also receive the notice. The caseworker must go into SASO and print a copy of Form 2101 from SASO and a copy of the email for the case record.

The regional nurse sends Form 2065-A, Notification of Community Care Services to the person within two business days of authorization.

4662.2 Authorization for Expedited Referrals

Revision 25-3; Effective June 1, 2025

When the provider verbally notifies the regional nurse that the practitioner's statement has been received, the regional nurse must ask for the:

• functional limitations;
• practitioner's name and license number; and
• signature date.

The regional nurse enters the information in the Service Authorization System Online (SASO) and generates Form 2101, Authorization for Community Care Services, within five business days, entering the negotiated date as the begin date. In Comments, the regional nurse enters the information on the verbal notification, including the provider representative and date of negotiation. Form 2101 must be sent to the provider within five business days of the negotiation. The regional nurse sends Form 2065-A, Notification of Community Care Services, to the person within two business days.

Each region must ensure there is always a caseworker available to negotiate a start of care date on expedited referrals.

The provider must send the completed practitioner's statement to the regional nurse within seven business days of service initiation. If a completed practitioner's statement is not sent to the regional nurse within seven business days of service initiation, the provider is not entitled to payment from the Texas Health and Human Services Commission (HHSC) until the date HHSC receives the completed practitioner's statement. In this instance, the regional nurse changes the service initiation date in SASO to the date HHSC receives the completed practitioner's statement and sends the provider a corrected Form 2101.

4663 Effective Dates

Revision 24-2; Effective June 1, 2024

The Texas Health and Human Services Commission (HHSC) regional nurse establishes the beginning date of coverage for initial Community Attendant Services (CAS) and Primary Home Care (PHC) cases on Form 2101, Authorization for Community Care Services, Item 4. This is the date the form is expected to be mailed to the provider or the date negotiated per the person’s needs and the unique circumstances of the case.

Review section 4664, Time-Limited Services, for more information.

4664 Time-Limited Services

Revision 26-1; Effective March 1, 2026

If the practitioner believes the person may not need ongoing services, they can put an end date on Form 3052, Practitioner's Statement of Medical Need. There are special procedures for handling the request.

• The initial assessment and referral processes remain the same.
• When the provider receives Form 3052, which shows a need for time-limited services, the provider sends a copy of the form to HHSC.
• The regional nurse for both PHC and CAS completes the authorization for services and enters an end date on Form 2101, Authorization for Community Care Services. Explain the reason for an end date in the comments section. Examples:
  • Person needs services because of a broken arm. A recovery is expected in three months.
  • Practitioner has specified time limited services ending on XXXXX.
• The caseworker enters a monitor date into the SASO scheduler. They monitor the person at least 30 days before the end date on Form 2101.
• The caseworker contacts the person at the scheduled time. They see if the person’s needs are met or if they need continued PHC or CAS services.
• If the person’s needs are met, the caseworker sends Form 2065-A, Notification of Community Care Services to  the person to close the case. They include a 12-calendar day prior notice and enter a date and termination code 14-No Medical Need on Form 2101. The effective date of termination on Form 2065-A is the same as the end date on Form 2101.
• The caseworker must:
  • Send Form 2065-A at least 12 calendar days before, but not more than 30 days before, the Form 2101 end date if the person wants to continue PHC or CAS services.
  • Tell the person that a new Form 3052 must be received before the end date of Form 2101 or services will be terminated.
  • Complete a new Form 2060, Needs Assessment Questionnaire, Task and Hour Guide, and a new Form 2101.
  • Advise the provider that a new Form 3052 is required.
• If the practitioner refuses to sign Form 3052, the caseworker screens the person for FC services. If eligible, the caseworker refers the person for FC services or places the person on the FC interest list.
• If the practitioner signs Form 3052, the case is authorized, and the person remains eligible for service. The caseworker must send a new Form 2065-A to inform the person of the new certification, within two business days from the regional nurse’s authorization. 

If a person on CAS has time-limited benefits, the regional nurse will add the end date. The caseworker must never change or delete the end date added by the regional nurse when adding an effective date for a plan change.

Example: A person is certified Jan. 2 for CAS with time-limited services ending Dec. 31. The regional nurse adds the end date of 12/31/XX. During the authorized period, the person requests a change in July that will be effective Aug. 1. When working the change, the caseworker must not change or delete the date added by the regional nurse to add an effective date for the change. The caseworker documents in the comments of Form 2101 the normal information about the change, including Increase in hours effective 08/01/XX. The caseworker still includes in the comments, along with the change information, that the person has time-limited benefits ending on 12/31/XX. This gives the provider the information about the change, including the effective date of the change, but will leave the end date intact.

Also use this process when a person’s time-limited benefits end after the annual certification. Using the same dates above, the caseworker sees the person for their annual reassessment on Oct. 5 and processes the case Oct. 10, leaving the end date in the authorization of 12/31/XX. Along with the regular annual reassessment comments, the caseworker adds the comment that the person has time-limited benefits ending on 12/31/XX. The caseworker will still follow the same procedure in the list above starting with the fourth bullet to set the scheduler 30 days before the end date to monitor the person’s time limited case.

4665 Service Initiation and Delivery

Revision 25-5; Effective Dec. 1, 2025

Refer to 26 Texas Administrative Code Section 277.61, Service Initiation.

4665.1 Delays in Service Initiation

Revision 25-3; Effective June 1, 2025

A provider may delay service initiation only for reasons not directly caused by the provider, or reasons beyond the provider's control, such as natural or other disasters per 26 Texas Administrative Code (TAC) Section 277.61(c), Delay in service initiation. The provider must continue efforts to initiate services and set a date for service initiation, if possible. The provider must document any failure to initiate services by the applicable due date in subsection (a) of this section, including:

• the reason for the delay, which must be beyond the provider's control;
• either the date the provider anticipates it will initiate services, or specific reasons why the provider cannot anticipate a service initiation date; and
• a description of the provider's ongoing efforts to initiate services.

Documentation of service initiation. The provider must maintain documentation of service initiation in the person's file.

Evaluate the cause of the delay and any necessary action to ensure the person receives services as soon as possible.

Example: The provider may state the person's physician is on vacation but is expected to return by a specific date and a practitioner's statement will be obtained as soon as the physician returns. If the delay will not adversely affect the person, the caseworker may decide to take no further action. If the delay is problematic for the person, the caseworker may discuss with the person the need to get a practitioner's statement from another practitioner. Appropriate action may necessitate making a new referral to a different provider.

Each situation is evaluated on a case by case basis. The provider may contact the caseworker's supervisor if the caseworker has a pattern of transferring people to other providers even though they have indicated that it is due to reasons beyond their control. The caseworker may also contact the contract manager if the provider frequently submits Form 2067, Case Information, to the caseworker about a delay in initiating services.

4665.2 Service Delivery Requirements

Revision 25-3; Effective June 1, 2025

The provider agency must ensure:

• services are delivered per the service plan described in 26 Texas Administrative Code Section 277.45 Pre-Initiation Activities;
• all authorized and scheduled services are provided to a person, except in the case of a service interruption; and
• during a calendar month person does not receive, more than five times the weekly authorized hours on Form 2101, Authorization for Community Care Services.

4670 Ongoing Case Management

Revision 17-1; Effective March 15, 2017

4671 Ongoing Caseworker Responsibilities

Revision 25-3; Effective June 1, 2025

Monitor the person per 2710, Monitoring Visits and Contacts, to review the continued adequacy of the service plan, the quality of service delivery and the person's condition.

The caseworker:

• reassesses the person's functional need within 12 months of the previous functional assessment date on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide. Review 2663, Reassessment of Functional Need; and
• reverifies financial eligibility status within 24 months of the previous eligibility date on the Service Authorization System. Review 2662, Redetermination of Financial Eligibility.

The caseworker provides ongoing case management to the person. They also report to and discuss with the unit supervisor, the contract manager, and the provider any apparent deficiencies noted in the provider's delivery of Primary Home Care or Community Attendant Services.

4672 Transferring People from Family Care to Title XIX Personal Attendant Services

Revision 25-3; Effective June 1, 2025

When the caseworker transfers a person from Family Care (FC) to Primary Home Care (PHC) or Community Attendant Services (CAS), send a referral packet to the receiving provider. The provider begins pre-initiation activities, and coordinates the end date for FC and begin date for PHC or CAS, with the regional nurse.

The FC authorization must be closed in the Service Authorization System before the PHC or CAS authorization can be opened. The regional nurse sends the person Form 2065-A, Notification of Community Care Services, within two business days of authorizing services as notification of the program change and if applicable of the change in providers.

4673 Interim Service Plan Changes

Revision 25-3; Effective June 1, 2025

The person may request a change in tasks or hours. Review 2720, Interim Changes.

The provider may also notify the caseworker of any ongoing change in the person's condition or circumstances that may require a service plan change or service termination. Any of the following changes in the person's condition or circumstances may require a change in the service plan. These are examples only.

• person's health improves or deteriorates;
• person stops needing services;
• person is discharged from a hospital;
• problems exist with family relationships;
• person is evicted or otherwise loses housing;
• person relocates;
• person is referred for home health services; or
• changes occur in the person's household composition.

4673.1 Temporary Service Plan Variances

Revision 25-3; Effective June 1, 2025

The provider may temporarily vary the service delivery plan at the person's request if the variance in tasks can be provided within the total approved hours. The caseworker will not be advised of the temporary variance unless the circumstance lasts for more than 60 calendar days.

The provider must provide services per the existing service delivery plan, until the provider receives a new Form 2101, Authorization for Community Care Services. The provider may temporarily change the service delivery plan if:

• the person requests and requires temporary help with allowable tasks not identified on the service delivery plan due to a change in circumstances or available supports; and
• the change in tasks does not increase the total approved hours of service or continue for more than 60 calendar days.

The provider must request and obtain a new Form 2101 when a temporary variance in tasks or hours on the service delivery plan:

• will continue for more than 60 calendar days; or
• would result in more hours of services provided than have been approved.

If the temporary variance lasts more than 60 calendar days, the provider must notify the caseworker and request a new Form 2101 for the change. The caseworker must follow normal procedures for responding to reported changes outlined in 2720, Interim Changes. If the provider does not request a new authorization, then the service plan delivery must go back to the original authorization of tasks and hours.

4673.2 Ongoing Service Plan Changes

Revision 25-3; Effective June 1, 2025

Refer to 26 Texas Administrative Code Section 277.67(a), Increase in hours or terminations.

If the caseworker receives a request for a change, they must respond to it within 14 calendar days from the date the request is received. Contact and review the person's service plan to decide if the change is necessary. If the caseworker decides the change is not necessary, document the reasons on Form 2067, Case Information, and send it to the provider. Send Form 2065-A, Notification of Community Care Services to the person. Document the reason and related handbook reference for the denial of the requested change in Form 2065-A comments section.

Depending on the person's new condition or situation, a new assessment or revision of the service plan such as the need for more hours or a different priority level may be necessary. If appropriate, make changes to the service plan on Form 2101, Authorization for Community Care Services, per 2720, Interim Changes. Consult with the supervisor about the requested change, if necessary. If the change in circumstances meets the criteria for Adult Protective Services, refer the person to that service. Review 2220, Response to Requests for Service.

For Community Attendant Services interim changes and provider transfers during the service plan year, the caseworker can authorize changes without authorization from the regional nurse. The caseworker enters the Begin Date on Form 2101 based on the case action increase or decrease. The effective date on Form 2065-A, Notification of Community Services, must match the Begin Date on Form 2101.

4673.3 Increase in Hours

Revision 25-3; Effective June 1, 2025

Set the begin date on the authorization form for expedited or routine service plan changes resulting in an increase in hours. The Begin date on Form 2101, Authorization for Community Care Services, must be seven calendar days from the Form 2101 date, unless an earlier date is negotiated.

There may be unique or extenuating circumstances when the increase is more than seven days. The caseworker must document the circumstances that require the delay. In these cases, the begin date of coverage is negotiated between the caseworker and the provider per the person’s unique needs. The increase should not be delayed because the delay is more convenient for the provider.

Send Form 2101 to the provider.

4673.4 Immediate Increase in Hours

Revision 25-3; Effective June 1, 2025

Refer to 26 Texas Administrative Code Section 277.67(c) Immediate increase in hours of service.

Upon notification from the provider that the person requires an immediate increase in hours, the caseworker or the designated caseworker immediately contacts the person to verify the need for the immediate increase. Review the tasks and hours on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, making the necessary revisions to the service plan. Contact the provider and negotiate an effective date for the increase. The request for an immediate increase must be responded to within the same day of the request. Within three business days, send a revised Form 2101, Authorization for Community Care Services, documenting the reason for the increase, the additional tasks and hours, the effective date and the provider representative contacted to negotiate the effective date. Review 2721, Service Plan Changes, for more information.

The following are examples of situations that require immediate response:

• The person is experiencing a major illness and has no available caregiver.
• The person suddenly loses their caregiver and has no other available caregiver and
  • is totally bedridden or unable to transfer from bed to chair without help; or
  • cannot manage toileting tasks without personal assistance; or
  • needs meal preparation or feeding to ensure that they receive daily nourishment.

Each region must ensure there is always a caseworker available to negotiate an immediate increase in hours.

4673.5 Termination or Reduction of Hours

Revision 25-3; Effective June 1, 2025

Reduce hours or terminate services when the person:

• requests a reduction or termination;
• gains a resource resulting in fewer unmet needs and the need to reduce service hours; or
• is performing all or some activities of daily living due to long term improvement in functional condition resulting in the need to reduce or terminate services.

Use personal judgment to determine if the person's long term improvement is expected to last through the current authorization period or beyond before services are reduced or terminated. If the caseworker determines the person's condition has temporarily improved because the person is performing the task(s) previously done by the attendant, the person and provider may agree to a temporary variance. To continue to qualify for Title XIX personal attendant services, the person must need at least one personal care task.

The regional nurse must authorize changes made in conjunction with an annual reassessment of Community Attendant Services cases.

For decreases, the change is effective 12 calendar days from the date in Item 1 on Form 2101, Authorization for Community Care Services, unless it falls on a weekend or a legal holiday. Complete Form 2065-A, Notification of Community Care Services if the person wants to waive or shorten the 12-day advance notice.  Use the effective date the person wants services to end or be reduced. Explain in the comments section that the person is voluntarily waiving or reducing their right to the 12-day advance notice. The person must:

• sign this statement; and
• be given the original and one copy of the notice.

The effective date of decrease on Form 2065-A, Notification of Community Care Services, must match the effective date of decrease entered in Item 4 of Form 2101.

If services are terminated, follow the notification procedures in 2810, Notice of Ineligibility or Service Reduction for a person. Coordinate the effective date of denial of services with the provider and regional nurse if appropriate to allow enough time for the person to appeal.

Refer to Appendix IX, Notification Effective Date of Decision, Appendix XVIII, Time Calculation and 2811, Effective Dates

4673.6 Temporary Loss of Eligibility and Reinstatement Procedures

Revision 25-2; Effective March 31, 2025

When a person loses categorical or financial eligibility for Title XIX services, Community Attendant Service (CAS), Primary Home Care (PHC) and Day Activity and Health Services, the caseworker must check the Texas Integrated Eligibility Redesign System (TIERS) to verify the denial and the reason. The caseworker must contact the person to discuss the situation and, if feasible, help the person with reinstatement of eligibility. If eligibility is reinstated without a gap in eligibility dates, no further action is needed. Review 3441, Loss of Categorical Status or Financial Eligibility, 3441.1, Procedures Pending Reinstatement, and 3441.2, Reinstatement Procedures After Denial, for caseworker procedures.

If the person's Medicaid or financial eligibility is later reinstated after a gap in eligibility, the person may not be automatically placed back on Primary Home Care (PHC) or Community Attendant Services (CAS), if the service has been terminated or transferred to Family Care (FC) during the suspension.

If HHSC notifies the provider that services are terminated, all pre-initiation activities, including medical need determination, must be completed before services are reinstated.

If the caseworker has sent Form 2101, Authorization for Community Care Services, terminating services or transferring to FC, then the caseworker must send a referral Form 2101 for PHC or CAS to the provider for pre-initiation activities. This includes a new Form 3052, Practitioner's Statement of Medical Need. Expedited procedures may be used in this situation, if appropriate. All policies regarding new referrals apply, including those for CAS and PHC for the authorization of services by the regional nurse. If the person was placed on Family Care (FC), the transfer between services must be negotiated with the regional nurse for end dates and begin dates and the person must be notified on Form 2065-A, Notification of Community Care Services.

4673.7 Implementation of Service Delivery Plan Changes

Revision 25-3; Effective June 1, 2025

The provider must implement the service delivery plan change on the later date from the following:

• the authorization begin date on Form 2101, Authorization for Community Care Services; or
• five calendar days after the date the provider receives Form and then use the authorization begin date on the form to determine timeliness.

If a provider does not implement a service delivery plan change on the effective date of the change, the provider must set a new implementation date. The provider must document any failure to implement a service delivery plan change on the effective date of the change, by the next business day. The documentation must include:

• the reason for the failure to implement the service delivery plan change in a timely manner; and
• the new implementation date.

4674 Service Interruptions

Revision 25-3; Effective June 1, 2025

A service interruption occurs anytime service delivery is discontinued for 14 or more calendar days. The provider should make every effort to ensure that interruptions in service last less than 14 calendar days, particularly if a break in service would jeopardize the person's health or safety. When an interruption of services is unavoidable, the provider must document in the person's file all service interruptions by:

• the 30th calendar day after the beginning of the service interruption for priority people; and
• the 30th calendar day that exceeds 14 calendar days after the service interruption for non-priority people.

The provider is not required to advise the caseworker that service interruptions have occurred. If the person contacts the caseworker or if the caseworker learns of the interruption during a monitoring contact, the caseworker takes the following actions:

• The caseworker contacts the person to determine if the service interruption is jeopardizing the person's health and safety or is having an adverse impact on the person.
• If there is no adverse impact and the person is willing to wait for services, the caseworker documents this information in the case narrative.
• If there is an adverse impact, the caseworker:
  • contacts the provider to determine the status of resuming services;
  • contacts the person and discusses the person's right to change providers if the provider cannot provide a resumption date; and
  • follows procedures in 4676, Change of Providers, if the person elects to change providers.

4675 Interdisciplinary Team

Revision 25-3; Effective June 1, 2025

The interdisciplinary team (IDT) is a designated group that includes the following people who meet when the provider identifies the need to discuss service delivery issues or barriers to service delivery:

• the person, the person's representative or both;
• a provider representative; and
• a Texas Health and Human Services Commission (HHSC) representative, who may be the:
  • caseworker or designee;
  • caseworker’s supervisor or designee;
  • contract manager or designee; or
  • HHSC regional nurse or designee.

An HHSC representative must attend all IDT meetings requested by the provider.

Additionally, the caseworker may choose to conduct an IDT meeting to resolve problems before the person elects to transfer from one provider to another. If the person remains dissatisfied or continues to request to change providers, they may do so. The person must always have the freedom of choice in selecting a provider and should not be required to go through the IDT process for this purpose. Review 4676, Change of Providers, for more information.

Review 4677, Suspension of Services and Interdisciplinary Team Procedures, for a detailed description of the IDT's role in service suspensions.

4675.1 People Report Service Delivery Issues

Revision 25-3; Effective June 1, 2025

A person has the right to voice grievances or complaints about the Texas Health and Human Services Commission (HHSC) staff or purchased services without discrimination or retaliation. The person has a right to report service delivery issues to the Health and Human Services Office of the Ombudsman at 877-787-8999. If the caseworker is aware of the issue, the caseworker must work to resolve the person's issues. Review policy outlined in 2736.1, Reporting Service Delivery Issues, for detailed procedures in handling service delivery issues.

4676 Change of Providers

Revision 25-2; Effective March 31, 2025

When the person plans to change providers, the person must first contact the caseworker who:

• coordinates the transfer to prevent a gap in coverage; and
• attempts to resolve any problems the person may have with the current provider before they process the transfer.

Within 14 calendar days after notification of a request to transfer providers, the caseworker contacts the person and the provider to determine:

• the person's reason for dissatisfaction; and
• if the person's satisfaction can be accomplished without changing providers.

The caseworker considers if the dissatisfaction is due to services not being provided per the service plan, problems with the attendant, problems with the provider, or the person's failure to comply with the service plan.

The caseworker may determine that an interdisciplinary team (IDT) meeting is appropriate to discuss the issues and find a resolution to the service delivery issues. Review 4675, Interdisciplinary Team, for more information. The caseworker may terminate the person's services if the person refuses more than three times to comply with service delivery provisions by repeatedly and directly, or knowingly and passively, condoning the behavior of someone in their home.

Within three business days of the IDT decision, the caseworker authorizes the transfer if:

• they determine that the person's satisfaction cannot be met without the person changing providers and services do not have to be terminated based on failure to comply with the service plan; or
• the person insists on transferring to another provider and the caseworker determines that services do not have to be terminated based on failure to comply with the service plan.

Within those three business days, the caseworker also:

• asks the person or the person's representative to select a new provider and documents the person's choice by:
  • coordinating with both providers the date the current provider will stop providing services and the date the new provider will begin services;
  • updating any pertinent information on Form 2059, Summary of Client's Need for Service;
  • updating Form 2101, Authorization for Community Care Services, for ongoing cases by entering the new nine-digit contract number in Item 2; and
  • documenting in the comment section the coordination with both providers and the effective date of the change.
• sends the new provider the updated Form 2101 and Form 2059; and
• sends the current provider a copy of the updated Form 2101 that includes the effective date the person changes to the new provider.

Review 26 Texas Administrative Code (TAC), Section 277.69

4677 Suspension of Services and Interdisciplinary Team Procedures

Revision 25-3; Effective June 1, 2025

A provider must suspend services if:

• a person temporarily or permanently leaves the provider agency’s contracted service delivery when the person would routinely receive services and does not request the provision of services outside the provider agency’s contracted service delivery area;
• the provider declines the request of the person for the provision of services outside of the provider agency’s contracted service delivery area and the person leaves the service delivery area;
• the person moves to a location where services cannot be provided under the PHC Program;
• the person dies;
• the person is admitted to an institution, which is a:
  • hospital;
  • nursing facility;
  • state supported living center;
  • state hospital;
  • intermediate care facility serving people with an intellectual disability or related conditions; or
  • correctional facility.
• the person requests that services end;
• the Texas Health and Human Services Commission (HHSC) denies the person's Medicaid eligibility not applicable to Family Care services; or
• the person or someone in the person's home exhibits reckless behavior, which may result in imminent danger to the health and safety of the person, the attendant, or another person in which case the provider agency must make an immediate referral to:
  • the Texas Department of Family and Protective Services or other appropriate protective services agency;
  • local law enforcement, if appropriate; and
  • the person's caseworker.

The provider agency may suspend services if:

• the person or someone in the person's home engages in discrimination against a provider or HHSC employee in violation of applicable law; or
• the person refuses services for more than 30 consecutive days.

The provider agency must notify the caseworker of any suspension by the first business day after the provider suspends services. The notice must include:

• the date of service suspension;
• the reason(s) for the suspension;
• the duration of the suspension, if known; and
• a written explanation of the circumstances surrounding the suspension.

Refer to 26 Texas Administrative Code Section 277.49 (d) Interdisciplinary Team (IDT) meeting, and Section 277.71 (e), Resuming services after suspension.

The provider must suspend services if the person:

• is not available to receive services;
• requests that services end;
• loses Medicaid coverage; or
• someone in the person's home exhibits reckless behavior that may result in imminent danger to the health and safety of the person, the attendant or another person.

The provider may suspend services if the:

• person or someone in the person's home engages in discrimination against a provider or HHSC employee in violation of applicable law; or
• person refuses services for more than 30 consecutive days.

In situations of reckless behavior, discrimination or refusal, the provider must convene an IDT meeting within three business days of the date the provider suspends services or identifies an issue that prevents the provider from carrying out a requirement of the program. The IDT meeting may be conducted by phone or in person.

The IDT must consist of:

• the person, the person's representative or both;
• a provider representative; and
• an HHSC representative, which may be the:
  • caseworker or designee;
  • contract manager or designee; or
  • HHSC nurse or designee.

If the provider cannot convene an IDT meeting with all the members present, the provider convenes with available members and sends documentation of the IDT meeting within five business days to the regional director for the HHSC region where the person lives. Participation by HHSC staff is mandatory. Staff must be aware of the requirements for participation in the IDT meeting. Based on a HHSC review of the IDT documentation, further action by the provider may be required.

During the IDT meeting, the team must:

• evaluate the issue;
• identify any solutions to resolve the issue; and
• make recommendations to the provider.

The caseworker takes the appropriate action following the IDT meeting, either terminating services or authorizing resuming services. Review 2820, Service Suspension by Providers. The provider must implement the recommendations of the IDT per Section 277.49(e) of the Texas Administrative Code.

4677.1 Person Temporarily Leaving Service Area

Revision 25-3; Effective June 1, 2025

A person may continue to receive services while they are temporarily staying at a location outside of the provider’s contracted service delivery area, but within the state of Texas. This helps prevent a disruption in services and protects a person’s health and welfare while they are traveling or staying at a location other than their residence.

When a person makes a request for services outside of the contracted service delivery area to the provider, the provider may accept or decline this request. If the provider accepts the person’s request, the provider may provide the allowed service to the person during a period of up to 60 consecutive days. The provider is not required to pay for expenses incurred by the provider’s employee who is delivering services outside the contracted service delivery area. Within three business days after the provider begins providing services outside of the contracted service delivery area, the provider is required to send a written notice to the caseworker notifying them:

• the person is receiving services outside of the provider’s contracted service delivery area;
• the location where the person is receiving services;
• the estimated length of time the person is expected to be outside the provider’s contracted service delivery area; and
• contact information for the person.

The caseworker receives written notification from the provider within three business days after the provider becomes aware of the person's return, when the person returns to the provider’s contracted service delivery area.

If the provider declines the person's request for services outside of the service delivery area, the provider informs the person or their primary caregiver, parent, guardian or responsible party, verbally or in writing, of the reason(s) for declining the request. The provider’s notice will also indicate that the person or their primary caregiver, parent, guardian, or responsible party may request a meeting with the caseworker and the provider to discuss the reasons for declining the request. The provider also informs the caseworker in writing, within three business days after declining the request, that the request was declined and the reason(s) for declining the request.

If the person requests an interdisciplinary team (IDT) meeting, the caseworker must convene an IDT meeting with the provider and the person or their primary caregiver, parent, guardian, or responsible party to discuss delivery of services outside the provider’s contracted service delivery area and possible resolutions. The caseworker must document the contacts with the person and the provider in the case record. If a resolution cannot be reached, the caseworker must offer the person a choice of providers or the Consumer Directed Services (CDS) option for services.

Out of Area Service Limitations

If a person receives services outside the provider's contracted service delivery area during a period of 60 consecutive days, the person must return to the contracted service delivery area and receive services in that service delivery area before the provider may agree to another request from the person for the provision of services outside the provider's contracted service delivery area.

If the person intends to stay outside the provider's contracted service delivery area for more than 60 consecutive days, the caseworker must transfer the person to a provider of their choosing with a contracted service delivery area that includes the area that the person receives services.

4678 Annual Reassessments

Revision 25-3; Effective June 1, 2025

The caseworker must make a home visit and face-to-face interview to conduct an annual functional reassessment and completion or review of Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, for Primary Home Care (PHC) people, every 24 months.

A home visit is not required for a PHC person if verification of financial eligibility status is not due at the next reassessment. The caseworker retains the ability to make a home visit if individual case circumstances require a home visit be made, as indicated in 2663.2, Determining When a Home Visit is Necessary for Other Services, case examples.

For Community Attendant Services people, the caseworker must make an annual home visit and face-to-face interview to conduct a functional reassessment. If the need for a change in tasks or hours is identified at the annual reassessment, Form 2101, Authorization for Community Care Services, is sent.

4678.1 Primary Home Care Annual Reassessments

Revision 25-3; Effective June 1, 2025

For Primary Home Care cases at reassessment with no changes, the service authorization is open-ended and nothing is sent to the provider. If there are changes in the service plan, within five business days of the annual contact, the caseworker must send the provider Form 2101, Authorization for Community Care Services, and appropriate forms as noted in Appendix XIII, Content of Referral Packets. Review Appendix IX, Notification/Effective Date of Decision, for effective dates.

4678.2 Community Attendant Services Annual Reassessments

Revision 25-3; Effective June 1, 2025

Reassess eligibility for Community Attendant Services (CAS) at least once every 12 months. The reassessment must include a functional assessment, a review by the provider, and an authorization determination by the regional nurse.

Complete the annual reauthorization by the end of the 12th month from the previous authorization. This is either the initial authorization or the last annual reassessment.

Example: CCSE staff complete the annual functional assessment by Oct. 31 and send the referral Form 2101, Authorization for Community Care Services, to the provider. The regional nurse's last annual reauthorization was on Nov. 20 in the previous year and this year will be due by Nov. 30.

Note: Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, is due by the end of the 12th month from the previous Form 2060.

CCSE Staff Procedures

Complete a functional assessment early enough for the reauthorization process to be completed within the 12-month time frame. If possible, complete the annual functional reassessment during the fourth 90-day monitoring visit for the year. If the annual reassessment is not completed during the fourth 90-day monitoring visit, then another home visit is required to complete the reassessment. The annual reassessment may be completed by phone if Form 2060 was completed within the last 60 calendar days due to an interim change.

Send Form 2101 to the provider within five business days from the home visit and:

• Indicate Annual Reassessment in the comments section on Form 2101.
• If there are changes in the service plan, enter the appropriate Begin Date on Form 2101 Enter the information in the Service Authorization System Online (SASO). Send Form 2065-A, Notification of Community Care Services, within two business days of the decision to advise the recipient of the changes in the service plan.
• If there are no changes in the service plan, indicate No Changes on the Form 2101 and leave the Begin Date blank.

For CAS or Primary Home Care services, if a recipient requests a change at the annual reassessment, the change must be worked within five business days or by the annual reassessment due date, whichever is earlier.

Regional Nurse Procedures for Annual Reassessments

For ongoing CAS cases, the regional nurse must review and authorize services annually in SASO. The authorization in SASO is required with or without any changes in the service plan. The annual reauthorization is due by the end of the 12th month from the last annual authorization. 
The provider must send Form 2101 to the regional nurse with a signed statement of the agreement or disagreement with the service plan, within 14 calendar days of receipt of the referral Form 2101 from CCSE staff.

Provider Agreement

If the provider agrees with the service plan, within five business days of receiving Form 2101 from the provider, the regional nurse completes the authorization of CAS as follows:

• If there are no changes to the service plan, the regional nurse enters the Begin Date, which is the same as the Mail Date, and sends the provider and CCSE staff a copy of the authorization Form 2101.
• If there are changes in the service plan, the regional nurse reviews the plan and authorizes the service based on the Begin Date CCSE staff entered. Enter the Mail Date and sends the provider a copy of the authorization Form 2101.
• The regional nurse notifies CCSE staff by either sending a paper copy of Form 2101 or notification of the authorization email.

If the region elects to have the regional nurse notify CCSE staff by email, the nurse must include the recipient's name, identification number, type of case action such as initial or annual reauthorization, and date of authorization in the email. The unit supervisor or other appointed HHSC staff will also receive the notice. CCSE staff must print a copy of the email for the case record and go into the SASO to print a copy of Form 2101 for the case record.

Provider Disagreement

If the provider disagrees with the service plan, within five business days of receiving Form 2101 from the provider, the regional nurse:

• negotiates with the provider and CCSE staff to arrive at an agreement on the service plan and the effective date of the change. If the negotiation results in a decrease in services, the effective date must allow time to provide the recipient with 12 calendar days advance notice on Form 2065-A from CCSE staff;
• makes any necessary changes to Form 2101, noting the negotiated change in the comments;
• completes the authorization in the Authorization Wizard;
• sends Form 2067, Case Information, notifying the provider and CCSE staff of the outcome of the negotiation; and
• sends a copy of the authorization Form 2101.

CCSE staff must send another Form 2065-A to the recipient, noting the negotiated service plan change(s) and the new effective date.

Tracking Receipt of Form 2101 from the Provider

CCSE staff are responsible for tracking the receipt of Form 2101 from the provider. If the authorization Form 2101 is not received from the regional nurse within 14 calendar days of the referral Form 2101 being sent to the provider, CCSE staff will check in SASO to see if services have been authorized by the regional nurse. If services have been authorized, CCSE staff print the authorization Form 2101 and file it in the case folder. If services have not been authorized, CCSE staff contact the regional nurse requesting services be authorized.

The regional nurse enters the authorization in SASO within five business days of receipt of the email from CCSE staff or Form 2101 from the provider, whichever is earlier. The regional nurse sends the provider a copy of the authorization Form 2101 and sends a copy or email to CCSE staff advising the authorization has been completed.

Related Policy

Annual Recertification, 6333.4
Workflow and Time Frames, Appendix IV

4710 Description

Revision 25-3; Effective June 1, 2025

Residential care (RC) services include RC and emergency care (EC).

Residential Care

• Contracted facilities serve eligible adults who require round-the-clock access to services. In RC services, the person must contribute to the cost of care, including a room and board payment and a copayment, if applicable.
• Review 4721, Residential Care Eligibility, for details about eligibility for RC.
• Review 4730, Special Casework Procedures for Residential Care, for special casework procedures for RC.

Emergency Care

• EC is available to eligible people for up to 30 days while the caseworker seeks permanent care arrangements. EC may be provided in adult foster care (AFC) homes and in RC facilities. If a person is not placed in a permanent care arrangement within the initial 30-day period, they are eligible to receive services for one 30-day extension for a total of up to 60 days.
• Review 4722, Emergency Care Eligibility, for details about eligibility for EC.
• Review 4770, Ongoing Casework Procedures, for special casework procedures for EC.

4711 Required Services

Revision 25-3; Effective June 1, 2025

Refer to 26 Texas Administrative Code Section 276.41(b), Required services.

A person in a residential care (RC) facility has access to services on an as-needed basis. Therefore, the frequency of a task is not designated.

4720 Eligibility for Service

Revision 17-1; Effective March 15, 2017

4721 Residential Care Eligibility

Revision 26-2; Effective June 1, 2026

Eligibility for residential care is based on the following criteria:

• A person must be income eligible or Medicaid eligible and not in an institution.
• The person must meet the functional need criteria as set by HHSC.
• The person’s needs may not exceed the facility’s capability under its licensed authority.
• The person must have financial resources at or below the level established by HHSC.
• The person must contribute to the total cost of care they receive, including payment for room and board.
• The room and board amount is calculated from the person’s gross income.
• The person is responsible for paying this amount directly to the provider agency.
• The person may be required to pay a copayment based on the amount of income remaining after all allowances are deducted. 

A person must score at least 18 on Form 2060, Needs Assessment Questionnaire, Task and Hour Guide, and have adequate income to pay the required room and board payment to become or remain eligible for Residential Care (RC). For other eligibility requirements, review:

• Age Limits, 3111;
• Resource Eligibility Criteria, 3200;
• Income Eligibility, 3300; and
• Residential Care and Emergency Care Mental and Physical Characteristics, Appendix VIII.

Related Policy

26 Texas Administrative Code Section 271.85

4722 Emergency Care Eligibility

Revision 25-5; Effective Dec. 1, 2025

Refer to 26 Texas Administrative Code Section 271.87, Eligibility for emergency care criteria.

4730 Special Casework Procedures for Residential Care

Revision 17-1; Effective March 15, 2017

4731 Assessment

Revision 25-5; Effective Dec. 1, 2025

If a person requests RC services, determine if services are open and space is available in an RC facility. If services are not open at that time, place the person on the interest list. If funding and RC spaces are available or if the person is released from the interest list, proceed with the eligibility determination and assessment.

Advise the person of spaces available in the RC facilities in their area and recommend the person visit the facilities. If the person selects a facility and wants to move to the facility, continue with eligibility determination.

To assess if an applicant qualifies for RC, interview the applicant to determine:

• if they meet the Community Care Services Eligibility (CCSE) income and resource limits;
• if they have adequate income to pay the required room and board payment;
• the extent of the applicant's functional disability by scoring their response to Form 2060, Needs Assessment Questionnaire, Task and Hour Guide;
• the applicant's appropriateness using the guidelines for appropriate and inappropriate mental and physical characteristics in Appendix VIII, Residential Care and Emergency Care Mental and Physical Characteristics; and
• if their needs can be adequately met at an RC facility.

A person is inappropriate for placement if their needs exceed the facility's capability under its licensed authority. Licensing Standards for Assisted Living Facilities are in 26 Texas Administrative Code Section 553.259. In general, an RC facility may provide services to a person whose needs correspond with those listed in the Appropriate Characteristics column of the mental and physical characteristics in Appendix VIII. The facility may not be capable of providing services to a person whose needs correspond with those listed in the Inappropriate Characteristics column. Because each person's case must be reviewed per the setting where care will be provided, the appropriate and inappropriate characteristics are only examples.

An assessment of a person being considered for RC should include a review of their personal abilities to perform activities of daily living, measured by Form 2060, Needs Assessment Questionnaire, Task and Hour Guide, and other functional areas, such as the need:

• for the routine daily care offered in a group-care setting;
• for a structured environment and the ability to tolerate it;
• and ability to interact with groups and to socialize daily;
• for a home or for one different from their current living environment; and
• for and ability to tolerate daily monitoring or supervision for behavior control or both.

By carefully assessing people in relation to the environment of RC facilities, the caseworker can develop care plans that make maximum use of the facilities' benefits.

Share findings with facility staff to determine if the person is a suitable candidate for RC and to facilitate a smooth transition.

Discuss money management with the person during the assessment. If the person expresses an interest in money management, inform the facility on Form 2067, Case Information, or in the comments section of Form 2101, Authorization for Community Care Services. Per 26 TAC  Section 276.61, Trust Fund Management, the facility must help the person manage their finances only if the person requests help in writing. The facility is not allowed to help a person write checks without first establishing a trust fund account for them.

4732 Freedom of Choice

Revision 25-3; Effective June 1, 2025

The applicant maintains freedom of choice among the facilities that serve their area.

The applicant can:

• select the facility; or
• choose to take the next facility on the rotation list.

The applicant must indicate their choice of available facilities before beginning the assessment process. If an applicant already has a facility in mind that has no space available, they may elect to remain on the interest list until a space is available in that facility.

4733 Referral

Revision 25-3; Effective June 1, 2025

Negotiate a move in date with the person and the facility once the applicant has:

• met all eligibility requirements;
• selected a facility; and
• been determined appropriate for placement in residential care (RC).

Refer to 26 Texas Administrative Code Section 276.39, Service Initiation.

To refer the applicant to the facility:

• complete Form 2059, Summary of Client's Need for Service, and Form 2101, Authorization for Community Care Services; and
• send these forms to the facility administrator.

If the applicant needs help managing their money, inform the facility:

• on Form 2067, Case Information; or
• in the comments section of Form 2101.

4733.1 Delay of Entry into the Facility

Revision 25-3; Effective June 1, 2025

If the person changes their mind, or for another reason does not move into the facility on the negotiated date, inform them that  they have three days from the negotiated date to enter the facility. If they do not move into the facility within those three days, the facility may give the bed space to another person, the referral for services may be withdrawn, and their request for services will be denied. If there are extenuating circumstances and the facility is willing to renegotiate a move in date, the date may be changed.

4733.2 Termination

Revision 25-3; Effective June 1, 2025

If the person does not move in and the move in date is not re-negotiated, begin termination procedures. Inform the person that their request for services will be denied and if they want to reconsider residential care (RC) placement later, their name will be placed on the interest list with a new request date.

Send the person Form 2065-A, Notification of Community Care Services. Cite Failure to follow the service plan as the denial reason. Send the facility Form 2101, Authorization for Community Care Services, to close the referral.

4734 Inappropriate for Residential Care

Revision 25-3; Effective June 1, 2025

Reassess the person upon return to the Residential Care (RC) facility if they were hospitalized or temporarily at a nursing facility or other institution. Complete the reassessment using the list of appropriate characteristics in Appendix VIII, Residential Care and Emergency Care Mental and Physical Characteristics, to ensure the person's needs do not exceed the facility's licensed capability to provide service to the person. Other circumstances may also require that the person be assessed for appropriateness. If the person no longer meets the appropriate characteristics, work closely with the facility to explore all available resources to arrange for the person's move. When arranging the move consider these other resources. This is a partial list:

• other agencies involved with the person;
• the person's family;
• area ambulance service; or
• the local sheriff's department.

4735 Duplication of Services

Revision 25-3; Effective June 1, 2025

A residential care (RC) person may receive Day Activity and Health Services (DAHS) only if the services the DAHS facility provides are medical services that the RC facility cannot provide. Documentation must clearly specify that at least one medical service is being provided at the DAHS facility that cannot be provided at the RC facility. For example, a person's needs are being met at the RC facility except for a daily insulin injection. The person goes to DAHS each morning for the DAHS nurse to administer the injection.

The number of units authorized to an RC person must be limited to the time needed by the DAHS facility to provide the medical services. Because most RC people are not high medical need people, the authorized services are limited to one unit, three but less than six hours per day.

4736 Transfers

Revision 25-3; Effective June 1, 2025

Once the person is in a facility, they have the right to move from one contracted residential care (RC) facility to another. If the person decides to move to another facility, contact the new facility to share information about the person's needs and to ensure that their needs can be met in the new facility. If the person is appropriate for the facility, negotiate a date of transfer, and update Form 2101, Authorization for Community Care Services, to reflect the change in facility. Send a copy of this form to the new facility and the former facility, noting in the comments section that the person's transfer was completed.

4740 Personal Contribution to the Cost of Care

Revision 25-5; Effective Dec. 1, 2025

A person must contribute to the total cost of the care they receive, including payment for room and board. The room and board amount is calculated from the person’s gross income. The person is responsible for paying this amount directly to the provider agency. The person may be required to pay a copayment based on the amount of income remaining after all allowances are deducted

A person is not eligible for residential care if they are required to contribute to the cost of their care but refuses to do so.

Related Policy 

26 Texas Administrative Code Section 271.85(b)
26 Texas Administrative Code Section 271.155(e) 

4740.1 Room and Board Payments

Revision 25-3; Effective June 1, 2025

People entering residential care (RC) are required to pay for room and board. The room and board payment is determined by a specific daily rate based on the type of residential setting. After deducting the room and board payment, the person's copayment is calculated based on personal needs allowance and any other approved deductions. The caseworker must complete Form 1032, Residential Care Copayment Worksheet. Form 1032 is an automated calculation worksheet for determining room and board and copayment amounts. A copy of the worksheet must be filed in the case record.

4740.2 Copayments

Revision 25-3; Effective June 1, 2025

Residential care (RC) includes a copayment system where the person is expected to contribute to the cost of care. Emergency care (EC) people do not contribute any copayment. Under the copayment system, each person is allowed certain monthly deductions for personal expenses and contributes the remainder of their income to the cost of care.

Withholding tax can be deducted from unearned income. Both withholding tax and Federal Insurance Contributions Act (FICA) tax can be deducted from earned income provided the deduction is mandatory. Other forms of mandatory deductions may be deducted if the caseworker can get documentation from the employer to confirm that the person does not have control of the expense being deducted. This includes mandatory repayments to the Social Security Administration (SSA) or other governmental agencies.

The copayment system takes into consideration the costs of non-Medicaid people who must pay for their own medical expenses. Medicaid people also keep a small allowance for medical expenses that are not covered by their Medicaid or Medicare insurance. If a person chooses to receive RC services, inform them about the mandatory contribution to the cost of care, and implications for their income and eligibility.

Review Form 1032, Residential Care Copayment Worksheet, and Instructions, for step by step instructions on calculating the person's total contribution to the cost of care.

4741 People on Services Before Sept. 1, 2003

Revision 25-3; Effective June 1, 2025

Beginning Sept. 1, 2003, people in residential care (RC) are required to pay room and board. People authorized for RC before that date were converted to the new payment system by dividing the current copayment into a room and board payment and a copayment.

A special payment system was implemented using non-Title XX funds for people authorized for RC before Sept. 1, 2003, with inadequate income to pay room and board. People in this category were automatically enrolled for the room and board payment with new service codes of 19O for the apartment setting or 19N for the non-apartment setting. The amount authorized is the difference between the person’s income and the room and board amount owed to the provider. People receiving the special room and board payment continue to be eligible for the payment if they remain in RC without a break in service. However, these people must pursue all possible sources of income and report new income to the caseworker. The new income is applied to the room and board fee.

State payment of room and board is available only for this group of people and does not apply to new applicants or people. Anyone authorized for RC after Sept. 1, 2003, must have enough income to pay the room and board fee for program eligibility.

4742 Caseworker Calculation Procedures

Revision 25-3; Effective June 1, 2025

The person's room and board is a set amount, however, the copayment amount varies based on their income and if they have Medicaid, Qualified Medicare Beneficiary (QMB) or Specified Low Income Medicare Beneficiary (SLMB) recipient. If a non-Medicaid, non-QMB or non-SLMB person receives Social Security or Railroad Retirement benefits, their Medicare premium is deducted from the gross amount of the benefit before the allowances are deducted. No other deduction is allowed. If the person has earned income, consider only the amount of net income over $65 per month. The net earned income is what the person takes home after all the deductions for such things as taxes and Social Security. Review Form 1032, Residential Care Copayment Worksheet, and Instructions, for instructions on calculating copayments.

Determine the amount that the person must contribute and enter the amount in Items 20 and 21 of Form 2101, Authorization for Community Care Services. Item 20 reflects the amount of copayment due for the first month of service. Item 21 reflects the ongoing copayment amount. Whenever cost-of-living changes increase benefits, review the affected person's cases and increase the copayment amounts accordingly. Increases are effective the first day of the month following the end of the 12-calendar day notification period.

Inform the person, in writing, about the fees they must contribute and advise them that if fees are not paid, they will no longer be eligible for residential care (RC). Send a copy of Form 2065-A, Notification of Community Care Services, to the person and the RC provider whenever there are changes in the fees the person must contribute.

The person's contribution to the cost of care must never exceed the daily RC rate established by the department.

4743 Waiver of Copayment

Revision 25-3; Effective June 1, 2025

A person's copayment, but not the room and board payment, may be reduced or waived because of unusual financial obligations such as high medical expenses or a need to purchase mobility aids. Consult with the supervisor to determine who in the region has the authority to waive the copayment for a residential care (RC) person.

Evaluate the persons circumstances to determine if their copayment should be reduced or waived. Regional staff may not allow a blanket reduction or waiver for all people served in an RC facility. Determine a specific period when the reduction or waiver is applied.

Document the basis for the reduction or waiver in the person's case folder if the copayment is reduced or waived. Forward a copy of the documentation to the provider. Complete Items 20 and 21 on Form 2101, Authorization for Community Care Services, to reflect waived or reduced copayments. Enter a statement in the comments section. Review the waiver or reduction before the waiver expires to determine if it should be continued. Document any continuation of the waiver.

4744 Adjusting Payments

Revision 25-3; Effective June 1, 2025

The caseworker is responsible for calculating the change in the person's copayment amount whenever there is a change in the person's income or an increase in the room and board rates.

Notify the person about a copayment increase or room and board rate change by using Form 2065-A, Notification of Community Care Services. The person must be given at least 12 calendar days after the Form 2065-A date to appeal the increase. If the person does not appeal, the increase is effective the first day of the following month.

The same day the person is notified, send the facility a copy of Form 2065-A with the new amounts. Send the facility Form 2101, Authorization for Community Care Services, showing the new copayment amount for increases in copayment. This gives the facility time to prepare to collect the new amounts. Send the facility another Form 2101 authorizing the original amount until the fair hearing is completed if the person appeals the increase during the 12-calendar day notification period.

Room and board rates are set amounts based on the living arrangement and will not change unless there is an across-the-board rate change. Only people designated on Sept. 1, 2003, to receive a room and board payment will have adjustments based on changes in their income. Review 4741, People on Services Before Sept. 1, 2003, for more details.

Copayments are based on the person's income. They will change at least yearly with the Retirement, Survivors and Disability Insurance (RSDI) or Supplemental Security Income (SSI) benefit cost-of-living increase. Caseworkers will be notified yearly of the increased amounts and procedures for adjusting the copayments.

4745 Collection of the Person's Contribution to the Cost of Care

Revision 25-3; Effective June 1, 2025

The facility must collect the person's room and board payment and copayment and must keep receipts for all copayments collected. The facility must deduct the copayment amount entered on Form 2101, Authorization of Community Care Services, and in the Service Authorization System Online (SASO) from reimbursement claims submitted to the department.

The facility collects the room and board payment and copayment monthly from the person by a set due date determined by the facility. If full payment is not made by the due date, the facility sends a notice to the person and notifies the caseworker using Form 2067, Case Information, by the first working day after the due date. When the due date falls on a holiday or a weekend, the facility collects the room and board payment by the first business day following the holiday or weekend.

Refer to 4774.1, Termination Due to Failure to Pay the Required Contribution to the Cost of Care, for procedures when Form 2067 is received from the facility stating that the person has failed to pay the required payments.

The facility must:

• keep receipts for each room and board payment collected;
• keep receipts for each copayment collected; and
• deduct all copayments from reimbursement claims submitted to the Texas Health and Human Services Commission (HHSC).

The person must pay their entire room and board payment. The person must also pay the entire copayment or request that the caseworker ask for a waiver, if financially unable to pay. Review 4743, Waiver of Copayment, for procedures.

4750 Personal Leave

Revision 25-5; Effective Dec. 1, 2025

The person is eligible for 14 days of personal leave from the Residential Care (RC) facility each calendar year. If the person does not pay the bed-hold charge for days of personal leave that exceed the limits, they may lose their space in the facility.

Inform the person that they are allowed up to 14 days per year of personal leave from the facility. Vacations and visits with family or friends are examples of personal leave. The person must pay the copayment and room and board charges for personal days. The facility may not bill HHSC for more than 14 days of personal leave taken by a person each calendar year.

If a person exceeds the allowable limit of 14 days of personal leave, they are responsible for paying all charges for services, per any existing contract or agreement between the person and the facility.

People who use excessive days of personal leave, as many as 30 days per year, but continue to pay bed-hold charges should be assessed to determine their need for RC. Determine if the institutional placement is still necessary, appropriate and in the person’s best interest.

Excessive use of personal leave may indicate that family members or friends are able and willing to have the person live with them. This option should be explored. Discuss excessive use of personal leave with the person to make sure they understand RC service limitations and requirements.

Related Policy

26 Texas Administrative Code Section 271.85(c) 

4760 Hospital, Nursing Home or Institutional Facility Stays

Revision 25-5; Effective Dec. 1, 2025

For the person to reserve their space in the facility during a hospital, nursing facility or institutional stay, the facility receives a bed-hold charge payment. The bed-hold charge is a set rate established by HHSC. As part of the bed-hold charge, the person is responsible for paying an amount equal to their room and board charge. HHSC then pays the difference up to the bed-hold charge. The amount HHSC pays is called the bed-hold rate.

The person does not pay their copayment while out of the facility for a hospital, nursing facility or institutional stay. If the copayment has been paid for the month and the person goes into a hospital, nursing home or institution, the facility must refund the copayment for the days the person is out of the facility.

After a hospital or nursing home stay, review the person’s condition to determine if the facility can continue to meet their needs per Appendix VIII, Residential Care and Emergency Care Mental and Physical Characteristics. Refer to 4734, Inappropriate for Residential Care, for other procedures if the person is no longer appropriate for residential care (RC). 

Related Policy

26 Texas Administrative Code Section 271.85(d)  

4770 Ongoing Casework Procedures

Revision 17-1; Effective March 15, 2017

4771 Facility Reporting and Notification Requirements

Revision 25-5; Effective Dec. 1, 2025

Refer to 26 Texas Administrative Code Section 276.45 Required Notifications.

If the caseworker receives a notice from the facility about a significant change, they must determine if the change is necessary within 14 calendar days of receiving the notice. Review 2811, Effective Dates, if the nature of the change requires termination of services.

4772 Monitoring

Revision 25-3; Effective June 1, 2025

Monitor the person's situation every six months. Review 2710, Monitoring Visits and Contacts for monitoring procedures. Assess the person's satisfaction with the facility and services delivered and the appropriateness of the service plan. If the person has any complaints about the facility or service delivery, report the situation to the facility directly or send Form 2067, Case Information. Work with the person and the facility to resolve the problem.

Report chronic problems to the unit supervisor, who may forward the information to the program manager and the contract manager.

4773 Annual Reassessment

Revision 25-3; Effective June 1, 2025

The caseworker must reassess the person annually for functional eligibility and redetermine financial eligibility within 24 months of the previous determination of financial eligibility. Review 2663, Reassessment of Functional Need, and 2662, Redetermination of Financial Eligibility, for more information about reassessments. Update any information on Form 2059, Summary of Client's Need for Services, and any changes to services on Form 2101, Authorization for Community Care Services. Send to the residential care (RC) facility.

Review 4774, Termination of Services, and 4734, Inappropriate for Residential Care, for procedures to help the person in relocation and termination if the person stops meeting eligibility requirements or being appropriate for placement in RC.

4774 Termination of Services

Revision 25-3; Effective June 1, 2025

The residential care (RC) person is not eligible for services if the person:

• dies;
• is admitted to an institution for more than 30 days;
• requests service termination;
• refuses to comply with their service plan;
• jeopardizes their or others' health or safety;
• loses Medicaid or becomes financially ineligible for services; or
• can contribute to the cost of their care but refuses to do so.

Do not terminate services if there is an adverse change in the person's health, but their needs can still be met by the facility.

Follow procedures in 2800, Procedures for Denying or Reducing Services when terminating services. Send the person Form 2065-A, Notification of Community Care Services, 12-calendar days before the effective date of denial, except in situations threatening the health or safety of the person or other people. Terminate services immediately in situations threatening health or safety as outlined in 2840, Threats to Health and Safety, and 2811, Effective Dates for Service Reduction and Termination.

The person has the right to appeal any adverse action within 90 calendar days of the date of Form 2065-A. The person may continue to receive services pending the outcome of the appeal hearing if the person:

• is provided with 12 calendar days advance notice, as specified in Section 2800 and Appendix IX, Notification/Effective Date of Decision; and
• notifies the caseworker within those 12 calendar days that they want to appeal the decision.

If the person does not appeal the service termination, the termination is final. If the person appeals the service termination notice, follow the Texas Health and Human Services Commission (HHSC) appeal procedures in 2830, Appeal Procedures.

4774.1 Termination Due to Failure to Pay the Required Contribution to the Cost of Care

Revision 25-3; Effective June 1, 2025

The facility must notify the person or representative and the caseworker in writing that payment was not received by the first business day after the due date if the person fails to pay the required contribution to the cost of care, room and board, or copayment by the facility's due date. The facility may notify the caseworker by the next business day, and follow up in writing within five calendar days of when the person or the person's representative fails to pay the required payments.

Upon receipt of the notice, the caseworker will:

• Coordinate with the facility to convene a meeting of the interdisciplinary team (IDT) within five business days of receipt of the notification.
• Include in the IDT the person, a facility representative, the caseworker and the person's authorized representative(s), if applicable.
• Explore with the person and IDT if there are new circumstances preventing the person from making the required payment.
• Consider these circumstances:
  • the person has a situation involving a mandatory recoupment or other changes in income requiring an adjustment in countable income;
  • the person meets any of the criteria for waiving the copayment amount, such as increased medical bills with more information in  4743, Waiver of Copayment;
  • circumstances indicate that the person is being exploited by another person; and
  • other situations exist where the person and facility can work out an agreement for the person to pay the required payments;
• Make every effort to resolve the problem with the person and the facility.
• Advise the person of the consequences that will result from refusal to make the required payments to the RC facility, including:
  • termination of eligibility;
  • eviction; and
  • being placed at the end of the interest list if they reapply for services in the future; and
• Ask the person to read and sign Form 2119, Residential Care, Adult Foster Care or Assisted Living Contribution Acknowledgement, if the situation cannot be resolved and the person continues to refuse to pay the required payments.

The form states that they refuse to pay the required payments and understand the consequences of not meeting this eligibility requirement. If the person refuses to sign, document the refusal on the form and have a witness sign. Leave the person a copy of the form and keep the original copy with the signature in the person's case record. Advise the person that they will receive a notice to terminate services. Also advise the person that they will not be allowed to move to another RC facility while they have an outstanding balance at the current facility, and the current facility may evict the person for refusal to pay. Coordinate the notice of termination with the facility.

After the IDT meeting, make any appropriate referrals to adjust countable income, request a waiver of copayment or refer to Adult Protective Services (APS), if exploitation is suspected.

If the situation cannot be resolved and the person is refusing to pay for any reason, the caseworker sends Form 2065-A, Notification of Community Care Services, giving the person a 30 calendar day notice that services will be terminated unless the person pays the required payments. In the comments section of the form, advise the person that services will end and the facility may evict the person if payment is not made by the 30th day. Send the facility a copy of Form 2065-A.

The facility may initiate the eviction proceedings by giving the person an eviction notice in writing.

If the person does not appeal, terminate services 30 calendar days from the Form 2065-A notice. The facility will receive payment from HHSC during the 30-day period. If the person has not made other living arrangements at the end of the 30 calendar days, make a referral to APS. Provided the facility is in compliance with the provisions of its license and contract for the eviction of people, the facility may evict the person on the date provided on the written eviction notice.

4774.2 Services During the Appeal

Revision 25-3; Effective June 1, 2025

The person may appeal the decision to terminate services. If the person makes the appeal request on or before the date of the action to terminate services, their case will remain open until a hearing decision is made. However, the facility has the right to continue with eviction proceedings and may evict the person with appropriate notice to the person, even if the hearing decision has not been made. No services will be provided.

4774.3 Requests to Transfer to Another Residential Care Facility

Revision 25-3; Effective June 1, 2025

The person may not transfer to another Residential Care (RC) facility if the outstanding payment was not made to the previous facility. The caseworker must maintain clear documentation about the person's refusal to pay and the subsequent actions.

If the person contacts another facility or the caseworker requests placement in a new facility, the gaining caseworker must contact the current caseworker to determine if the person is current on all required payments. If the person has outstanding payments to a facility, the caseworker will not approve ongoing RC services at a new facility and the request to transfer will not be processed. The person may receive other services, if determined eligible, but will remain ineligible for RC services until all outstanding payments are made.

4780 Special Casework Procedures for Emergency Care

Revision 17-1; Effective March 15, 2017

4781 Caseworker Assessment

Revision 25-3; Effective June 1, 2025

Respond to a request for emergency care (EC) the same day the report is received. If a person is in an emergency situation because they need a home and no other care arrangement is available, determine if they meet the remaining eligibility criteria for EC. If they do, complete the eligibility determination process within one business day after they enter the facility.

A person who moves into a residential care (RC) facility or an adult foster care (AFC) home for EC must meet eligibility requirements for EC and meet the mental and physical characteristics specified in Appendix VIII, Residential Care and Emergency Care Mental and Physical Characteristics. If necessary, consult the regional nurse.

4782 Immediate Placement

Revision 25-3; Effective June 1, 2025

Make the referral by phone to expedite the person's move into the facility. If space is available, help them and their caregivers arrange for transportation to the adult foster care (AFC) home or the residential care (RC) facility. If the caseworker determines that the person does not meet the eligibility criteria and the appropriate characteristic criteria for emergency care (EC), help them make other arrangements. An ineligible person must leave the EC facility within five calendar days of the date they entered.

The provider is entitled to payment for EC services for up to five calendar days after date of entry, no matter the applicant's eligibility status.

If the provider determines that the person's needs exceed the facility's capability under its licensed authority, the provider may request another review by the supervisor in consultation with the regional nurse. Regional staff are responsible for developing review procedures. The caseworker is responsible for making the final decision on the person's appropriateness for RC services.

4783 Length of Stay

Revision 25-3; Effective June 1, 2025

Residential Care (RC) is provided for up to 30 calendar days while you seek a permanent care arrangement within the initial 30-day period. Get your supervisor's approval to extend Emergency Care (EC) beyond 30 calendar days. Get this approval before the first 30-day period expires.

Note: An extension must not exceed 30 calendar days.

Revision 17-1; Effective March 15, 2017

4910 SSPD Program Description

Revision 25-5; Effective Dec. 1, 2025

Special Services to Persons with Disabilities (SSPD) helps people with disabilities achieve habilitative or rehabilitative goals per their service plan.

The service plan is developed by the provider agency and must contain the following information:

• services;
• tasks; and
• frequency of services a particular person will receive.

These services must be part of the provider agency's service array outline in the plan of operation.

Services included in the service plan include counseling, personal care and help with the development of skills needed for independent living in the community. Support services may include transportation, information and referral.

Services vary depending on the regional contract. The Community Care Services Eligibility (CCSE) supervisor can provide specific information about regional contracts.

Refer to Appendix XX, Mutually Exclusives Services for other services that can be authorized with SSPD services.

4920 SSPD Eligibility

Revision 25-3; Effective June 1, 2025

To be eligible for Special Services to Persons with Disabilities (SSPD), the applicant must:

• be at least 18 or older;
• have Medicaid or meet financial eligibility criteria; and
• have a functional assessment score of at least nine.

Use the guidelines in Appendix III, Appropriate or Inappropriate Individual Characteristics Special Services to Persons with Disabilities, to determine if the applicant’s needs can be met adequately by the SSPD PAS program if the applicant appears to need personal attendant services (PAS). Applicants may be admitted to the attendant services program only if their needs do not exceed the program's available services.

Related Policy

Notice of Ineligibility or Service Reduction, 2810
Eligibility for Services, 3000

4930 Service Referral, Initiation and Delivery

Revision 25-3; Effective June 1, 2025

Special Services to Persons with Disabilities (SSPD) is currently available only in regions 03 and 07. Complete and send Form 2101, Authorization for Community Care Services to the provider to refer interested people in these locations. Conduct reauthorizations annually per the same procedure. Follow procedures in 2550, Identifying People at Risk when necessary.

The provider agency must develop the service plan before services can be started.

• The provider agency must start services:
  • within 14 calendar days after the referral date on the HHSC Authorization for Community Care Services form; or
  • as required by the procedures developed in the HHSC region where services are delivered.

The provider agency may deliver services in the following settings:

• an adult day care facility; or
• other settings approved by the contract manager.

Revision 24-3; Effective July 1, 2024

The Texas Health and Human Services Commission (HHSC) implemented processes for Utilization Review (UR) in the Community Care Services Eligibility (CCSE) Services, effective March 1, 2009.

The UR process for CCSE includes concurrent reviews of a random sample of cases for people receiving:

• Primary Home Care; and
• Community Attendant Services (CAS).

A concurrent review is a UR of an ongoing service where the cases are randomly selected. They do not occur during the application process. 

5110 Concurrent Reviews of Randomly Selected Active Cases

Revision 24-3; Effective July 1, 2024

Concurrent reviews are conducted on a random sample of active Primary Home Care (PHC) and Community Attendant Services (CAS) cases. The utilization review nurse contacts the caseworker and requests all or a portion of the documentation specified for the review. The caseworker provides the documentation within seven calendar days of the request. Depending on available information, the UR nurse may make a home visit or a Home and Community Support Services agency visit in addition to a desk review.

5200 Utilization Review Report to the Regions

Revision 24-3; Effective July 1, 2024

Concurrent Utilization Review (UR) may have findings or no findings to report to the region.

If any findings or information need to be relayed to the region, the UR manager emails the complete UR tool to the regional director (RD) or their designee. Once the UR tool indicating a required action in the Findings/Summary section of the UR tool is received, the region can either:

• file an exception within five business days of receipt of the UR tool (review Section 5500, Utilization Review Exception Process, for guidelines); or
• contact the assigned caseworker and require the UR recommended changes be implemented.

If there are no findings, the UR nurse contacts the caseworker by phone or email to inform the caseworker there were no findings. The UR tool will not be forwarded to the region, and no documentation is required in the case record for a concurrent review with no findings. 

5210 Other Utilization Review Reporting Processes

Revision 24-3; Effective July 1, 2024

The Utilization Review (UR) nurse manager informs the regional director (RD) within one HHSC business day if the following situations are identified during any UR:

• immediate threat to health or safety or medical emergency involving the person;
• risk or threat of danger to a person;
• abuse, neglect, or exploitation of a person;
• violation of individual rights, problem with quality of services, potential fraud, or potential threat to health and safety; and
• fraud, waste, and abuse of services. If indicated, the RD will make a referral to the Office of Inspector General through established procedures and report the referral to the UR manager.

Revision 24-3; Effective July 1, 2024

For a concurrent review with findings for Primary Home Care (PHC) or Community Attendant Services (CAS) cases, the Utilization Review (UR) nurse contacts the caseworker and requests the documentation for review. The caseworker provides the documentation within seven calendar days of the request. Depending on available information, the UR nurse may make a home visit or a Home and Community Support Services agency visit in addition to a desk review.

If a concurrent UR results in a recommendation to decrease, increase or deny services, or identifies a policy compliance or quality of care issue, the UR nurse manager reviews the case. If the UR nurse manager concurs, they email the UR tool to the regional director (RD) of the region where the person lives. If the RD has a designee, only the baseline information and the findings are sent.

The RD or designee reviews the case and contacts the UR nurse manager, state office UR manager, or both for any additional information needed. UR staff immediately provide the RD with the requested information.

The RD has seven business days  after receiving the information from the UR manager to respond to the UR finding. During this time, the RD may:

• agree with the UR finding and direct regional staff to implement the finding;
• discuss the finding with the UR manager through an informal exception process; or
• file a formal exception to the findings with state office.

If the RD attempts to phone the UR nurse manager to discuss the findings in an informal exception process for a concurrent UR, and the UR nurse manager is unavailable. In that case, the UR nurse manager or designee returns the contact within two business days. If a discussion or informal exception process between the UR nurse manager and the RD  results in changes to the UR finding, the UR nurse manager makes the changes to the electronic version of the UR tool and emails the final copy of the revised tool to the RD and caseworker.

If the UR finding is not changed through the informal exception process and the RD disagrees with the final findings, the region can either:

• note the disagreement and direct regional staff to implement the finding, if indicated; or
• file a formal exception with state office. If a formal exception is filed, the RD will notify the UR nurse manager via phone or email of the date the exception is filed.

If the RD agrees with the UR recommendation, the RD will notify the UR unit of the agreement and direct the caseworker to implement the UR finding within one HHSC business day.

If no formal exception is filed and the UR finding recommends a change to the existing service plan, the RD’s seven-business-day time frame is part of the 14-calendar-day time frame that a caseworker has to complete a change request. 

5310 Personal Attendant Services

Revision 25-4; Effective Sept. 1, 2025

The regional director (RD) or designee notifies the caseworker to implement the Utilization Review (UR) findings. They will provide the date for completion and any specific instructions about the UR findings. The caseworker files a copy of the findings page(s) and all service planning documents completed by the UR nurse in the case record to support justification for the changes made to the person’s services. Under no circumstances should the entire UR tool be filed in the case record.

The caseworker follows the time frames and procedures below to implement the UR findings.

The UR findings for concurrent reviews must be implemented within 14 calendar days of the date:

• the UR manager notifies the RD of the UR findings unless a formal exception is made; or
• state office issues a decision on a formal exception.

To implement the UR findings, the caseworker may be required to increase, decrease, add or terminate services. The caseworker follows the current policy for changing service authorizations. This includes:

• discussing the UR Form 2060, Needs Assessment Questionnaire and Task and Hour Guide, tasks and allocated time changes with the person for UR recommended changes to Personal Attendant Services (PAS);
• documenting the discussion with the person in the case record;
• completing Form 2065-A, Notification of Community Care Services, documenting the action taken;
• registering the change in the Service Authorization System Online (SASO), as applicable;
• sending a copy of Form 2065-A to the person; and
• sending Form 2101, Authorization for Community Care Services, to the service provider.

The caseworker must make sure that all service criteria is met when completing the changes. The caseworker must also make sure that the most current Form 2060 is entered in the SASO Functional Wizard and maintained in the case record. 

5320 Individual Agreement or Disagreement with the Change