4600, Primary Home Care and Community Attendant Services

Body

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:

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:

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:

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:

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:

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:

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:

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:

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:

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:

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:
  • 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