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.