Form 2813, Youth Empowerment Services (YES) Waiver Minor Home Modification (MHM) Request

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Effective Date

3/2026
2813.pdf

Instructions

Updated: 3/2026

Purpose

MHMs are physical modifications to a participant’s home. They are medically necessary to support the participant’s ability to function independently at home and in the community. Use MHMs to make necessary accessibility and safety related adaptations to a participant’s home.

Special Requirements

All MHMs must adhere to Americans with Disabilities Act (ADA) requirements, meet Texas Accessibility Standards, and meet applicable state and local building codes. The Wraparound facilitator should also ensure that the intervention is the most inclusive and person-centered option and that the Wraparound team (WT) agrees with the intervention requested. Note documentation of the MHM in the Wraparound Plan and retain it in the participant’s record.

Restrictive Interventions

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

  • Door and 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.

Limitations

If a MHM is requested and the YES Waiver participant or their legally authorized representative (LAR) do not own the home where the modification will take place, the CWP is responsible for getting a written agreement from the homeowner, landlord, or other property owner before a modification is purchased or installed.

Procedure

When to Prepare

The Wraparound facilitator completes this form per the Wraparound Process. Discuss the MHM during the Wraparound team meeting (WTM) and document in the Wraparound plan before submitting the MHM request form. Documentation must include a brainstorming process.

Submission

If the MHM is less than $500, complete Sections 1, 2, 3, 5 and 6. If the MHM is more than $500, complete Sections 1, 2, 3, 4, 5 and 6.

Submit a separate MHM request form for each individual item requested. Complete all sections of the MHM request form accurately. If the Local Mental or Behavioral Health Authority (LMHA or LBHA) does not complete all sections of the MHM request form, it is considered incomplete. It will not be reviewed.

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

Review Process

HHSC assigns a unique case number to the submitted request upon receipt of the MHM request form. All requests are reviewed per the YES Waiver Policy Manual and Medicaid requirements. If more information is needed to complete the review process, LMHA or LBHA staff have three business days to provide any other information or documentation that was requested. Once HHSC has finished reviewing the request, the LMHA or 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.

Participant Address, City, State, ZIP Code – Enter the participant’s full address. This should be the address where the MHM is used.

Local Mental Health Authority (LMHA) or Local Behavioral Health Authority (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 MHM request form. HHSC will contact the wraparound supervisor with questions about the MHM.

Comprehensive Waiver Provider (CWP)– Enter the CWP’s name.

Section 2- Property Information

The landlord or owner of the property where the MHM is to be made must complete this section before the modification is started.

Does the participant live in a property that is leased? – Check the appropriate box. If the answer is yes, approval from the property owner is required.

Name of Landlord – Enter the name of the landlord or owner of the property. Check the appropriate box.

Signature of Landlord and Date – The landlord or owner of the property must sign and date the form. Note: If the landlord or property-owner does not approve, the MHM cannot be made to the residence.

Section 3 - Requested Service

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

  1. Description and Cost of MHM 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. Reason for Participant Referral to YES Waiver – Enter the reason the participant was first referred to the YES Waiver. Include any related mental health condition(s) or diagnosis that pertain to the requested item, service or identified need(s) on the Child and Adolescent Needs and Strengths (CANS) assessment.
  3. Describe the medical necessity for MHM relating to the reason for 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.
  4. Describe how the requested MHM will supplement services already identified on the Wraparound Plan. How will this help decrease or remove barriers to services? How will it increase 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 MHM should be used by the participant to address MHM as a part of the plan of care. Include how the MHM will be monitored for efficacy.
  5. Describe the brainstorming process used to arrive at this MHM. Include strategies and tasks assigned to each team member. – Describe how the WT has strategized to meet the underlying need, including to the MHM request. Include a description of how the strategies and tasks related to the MHM request address sustainability.

Section 4: Required only for requests that are over $500.

The Wraparound facilitator, with the help of the CWP 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. – Check the appropriate box. Outline bids, including the name of service or item and cost of each item if the answer is yes. 

2. Is this request or bid the most cost-effective option? – Check the appropriate box. Provide the reason for not choosing the most cost-effective option if the answer is no.

Section 5 - 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 MHM. – The Wraparound supervisor must review the YES Waiver Policy Manual outlining policy requirements for MHM. Check the appropriate box.
  2. MHM 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. – Check the appropriate box.
  3. MHM requested is tied to a strategy associated with an underlying need that was identified during Wraparound team meetings (WTMs) in fidelity to the Wraparound model.  – Check the appropriate box.
  4. All other strategies, payment, discounts, community resources, etc., have been explored and exhausted through the team task assignments, and Medicaid is the payer of last resort. – Check the appropriate box.

  5. If the request is made before the first WTM, the requested MHM is tied to a crisis or safety plan. It is necessary before the first WTM. – Check the appropriate box. 

    Explain, if answer is yes. – Describe how the MHM is included in the crisis or safety plan.

Section 6: Signatures.

Signature of LMHA or LBHA YES Supervisor or Program Manager and Date– The LMHA or LBHA YES program supervisor or program manager signs and dates the form.

CWP Signature – The CWP representative signs and dates the form.

Section 7: HHSC Authorization Status

To be completed by HHSC only.

HHSC YES Waiver staff approval or denial and signature must be obtained before MHM request on the Individual Plan of Care. – Choose appropriate answer. Provide reason for denial if applicable.

Approved – HHSC agrees that the item requested is justified based on necessity and appropriateness of the item or service based on information given. The LMHA or LBHA must attach the MHM form, signed by HHSC, into the CMBHS system in the IPC Document. Include a brief description of the MHM in the IPC MHM justification box.

Note: The MHM is not formally authorized until it is approved in CMBHS. Receipts of purchased items and the MHM request form must be kept in the participant’s record.

Denied – Based on information presented, the MHM cannot be authorized because it does not meet HHSC requirements.

  • Do not submit the MHM 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.
  • The MHM request form must be kept in the participant’s record.

HHSC YES Waiver Staff Determination and Signature – HHSC indicates a decision of the MHM Form.