Form 2812, Youth Empowerment Services (YES) Waiver Adaptive Aids and Supports (AAS) Request

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Effective Date

2/2026
2812.pdf

Instructions

Updated: 3/2026

Purpose

AAS are one-time or occasional goods and services. They were identified as necessary to help the participant stay in the home and community and avoid an out-of-home placement. Per the Center for Medicare and Medicaid Services (CMS), adaptive aids must be medically necessary to treat, rehabilitate, prevent, or compensate for conditions related to the participant’s mental health condition(s).

All AAS requests must be individualized, developed through the Wraparound process with the Wraparound team (WT), and be connected to a strategy to help the participant meet their treatment goals. During the monthly Wraparound team meeting (WTM), the Wraparound facilitator must document and show evidence that the AAS is being used and monitored for efficacy.

Special Requirements

Some AAS requests may need more evidence of medical necessity to be approved.

Restrictive Interventions

Some adaptive aids may be considered a restrictive intervention. Examples of restrictive interventions include, but are not limited to:

  • door or window alarms added to a participant’s environment;
  • security cameras;
  • locked access;
  • restricted access to personal property.

When the request is considered a restrictive intervention, the Comprehensive Waiver Provider (CWP) must inform the participant of their rights, including how to report abuse, neglect and exploitation. Include the informed consent and explanation of rights in the participant’s Crisis and Safety Plan and the Wraparound Plan of Care.

Limitations

AAS cannot be used to pay for services that are:

  • used for purposes that do not have a therapeutic objective;
  • provided in lieu of an available service in the YES service array;
  • goods and services that a household, not including a person with a disability, would be expected to pay for; and
  • goods or services for someone other than the participant.

Refer to the Policy Manual’s Appendix C: Non-Billable List for a comprehensive list. AAS and minor home modifications are limited to an annual maximum combined amount of $5,000 per participant.

Procedure

When to Prepare

The Wraparound facilitator only completes this form per the wraparound process. Discuss the AAS during the WTM and document in the Wraparound Plan, before submitting the AAS request form.

Submission

Complete Sections 1 and 2 if the AAS is less than $500. Complete Section 1, 2 and 3 the AAS is more than $500.

Submit a separate AAS request form for each individual request. The submitted AAS request form must be completed accurately. If the Local Mental Health Authority (LMHA) or Local Behavioral Health Authority (LBHA) does not complete all sections of the AAS request form, it is considered incomplete and will not be reviewed.

The YES Program Manager must submit the completed form to HHSC YES Waiver inbox at YESWaiver@hhs.texas.gov to be processed.

Review Process

Upon receipt of the AAS request form, HHSC assigns a case number to the submitted request. All requests are reviewed per the YES Waiver Policy Manual. If more information is needed to complete the review process, LMHA or LBHA staff have three business days to provide more information or documentation that was requested. Once HHSC finished reviewing the request, the LMHA/LBHA is notified of the decision by email.

Detailed Instructions

Section 1 – Participant Information

The LMHA or LBHA completes this section.

Date — Enter the date the service was requested.

CMBHS ID No. — Enter the participant’s Clinical Management for Behavioral Health Services (CMBHS) ID number.

Participant Name — Enter the participant’s name.

LMHA or LBHA — Enter the LMHA or LBHA’s name.

Wraparound Facilitator — Enter the Wraparound facilitator’s name.

Wraparound Supervisor — Enter the name of the Wraparound supervisor who has reviewed the AAS request form. HHSC contacts the Wraparound supervisor with questions about the AAS.

CWP — Enter the CWP organization’s name.

Section 2–Requested Service

The Wraparound Facilitator completes this section that address the related condition and the expected benefits of the requested item or service.

  1. Describe cost of AAS request — Enter the individual item or service requested. Include details, specification, or brand names as necessary to describe the request. Include the total cost of the request and where the request will be purchased.
  2. Describe medical necessity for AAS pertaining to the referral and prevention of out-of-home placement — Provide a detailed description of the participant’s functional limitation(s) relevant to the requested item. Describe why the item is necessary and how the item benefits the participant in terms of treatment, rehabilitation, or ability to compensate for functional limitations. 
  3. Describe how the requested AAS supplements services identified on the Wraparound Plan to decrease or remove barriers to services. Explain how the AAS increases the participant's access to their community -- Provide a detailed description of how the requested item will supplement authorized services offered included in the YES Waiver service array. Include a description of how the AAS is intended to be used by the participant to address the reason for referral and how the WT is incorporating the AAS as a part of plan of care.
  4. Was the brainstorming process used to arrive to this AAS? Are strategies and tasks assigned to each team member on the Wraparound plan? — Document a detailed description of all strategies, payment options, discounts, community resources, and other efforts explored and exhausted through tasks assigned to team members in the Wraparound plan. Select Yes or No.

Section 3 – Required Only for Requests Over $500

The Wraparound facilitator, with the assistance of the CWP organization representative, if necessary, completes this section related to cost of item or service requested.

  1. Has the YES CWP obtained three bids? Refer to YES Waiver Policy section 7000.1— Select Yes or No. Outline bids, including name of service or item and cost of each, if the answer is yes.
  2. Is this request or bid the most cost-effective option? — Select Yes or No. Provide the reason for not choosing the most cost-effective option if the answer is no.

Section 4 – Wraparound Supervisor Completes

The Wraparound supervisor must review the request with the Wraparound facilitator to confirm that the request meets YES Waiver policy criteria and that the Wraparound process was followed per the Wraparound model.

  1. Per YES Waiver policy, this request meets criteria for what is an allowable AAS. Refer to YES Waiver Policy Manual Section 7000.1 and Appendices C and D: Non-Billable and Heightened Scrutiny. — The Wraparound supervisor must review the YES Waiver Policy Manual outlining policy requirements for AAS, including the Non-Billable and Heightened Scrutiny requirements. Select Yes or No.
  2. The AAS requested is tied to the participant’s serious emotional disturbance and reason for referral. It is medically necessary and mandatory to prevent institutionalization and out-of-home placement.— Select Yes or No.
  3. The AAS requested is tied to a strategy associated with an underlying need. The need was identified during  Wraparound team meetings (WTMs) in fidelity to the Wraparound model — Select Yes or No.
  4. All other strategies, payment, discounts and community resources were explored and exhausted through the team task assignments. Medicaid is the payer of last resort. — Select Yes or No.
  5. Tie the requested AAS to a crisis and safety plan if the request is made before the first WTM. This is necessary before the first WTM. — Select Yes or No. Explain if the answer is yes.  Describe how the AAS is included in the crisis and safety plan.

Section 5 – YES and CWP Signatures

Signature of LMHA or LBHA YES Supervisor or Program Manager — The YES Program signature signs and dates the form.

Signature of CWP Representative — The CWP representative signs and dates the form.

HHSC Authorization Status

To be completed by HHSC only.

HHSC YES Waiver Staff Determination and Signature — HHSC indicates a decision of the AAS Form.

Approved — Based on information presented, HHSC agrees that the item requested is justified based on necessity and appropriateness of the item/service. The LMHA or LBHA must attach the AAS form, signed by HHSC, into the CMBHS system in the IPC Document. A brief description of the AAS must be included in the IPC AAS justification box. Note: The AAS request is not formally authorized until it is approved in CMBHS. Receipts of purchased items must be retained in the participant’s file.

Denied—Based on information presented, the item or service does not meet HHSC requirements and is not authorized.

  • Do not submit the AAS request into the CMBHS system.
  • The LMHA or LBHA must send Forms 2800 and 2801, Denial of Eligibility and Fair Hearing Request forms to the participant. The LMHA or LBHA must include the reason for denial provided by HHSC.