How To Get A Health Care Benefit In Texas

Transcription

1 RULE Purpose (a) This chapter governs provisions related to the Community First Choice (CFC) benefit. (b) CFC establishes a new state plan option to provide certain home and community based supports. RULE Definitions The following terms, when used in this subchapter, have the following meanings unless the context clearly indicates otherwise. (1) Activities of daily living (ADLs) -- Basic personal everyday activities including, but not limited to, tasks such as eating, toileting, grooming, dressing, bathing, and transferring. (2) CFC Emergency Response Services -- Back-up systems and supports including electronic devices with a backup support plan to ensure continuity of services and supports. (3) CFC Habilitation -- Acquisition, maintenance, and enhancement of skills necessary for the individual to accomplish ADLs, IADLs, and health-related tasks. (4) CFC Personal Assistance Services -- Personal assistance services provide assistance to an individual in performing the ADLs and IADLs based on the person-centered service plan. (5) CFC Support Consultation Services -- An optional service offered to individuals using the consumer directed services option. (6) Consumer Directed Services (CDS) option -- A service delivery option (also known as selfdirected model with service budget) in which an individual or legally authorized representative employs and retains service providers and directs the delivery of program services. (7) Financial Management Services Agency (FMSA)-- An entity that contracts to provide financial management services (FMS). (8) Financial Management Services -- Services including, but not limited to, the following activities: collect and process timesheets of the individual s attendant care providers; process payroll, withholding, filing, and payment of applicable Federal, State, and local employment related taxes and insurance; separately track budget funds and expenditures for each individual; track and report disbursements and balances of each individual s

2 funds; process and pay invoices for services in the person-centered service plan; and provide individual periodic reports of expenditures and the status of the approved service budget to the individual and to the State. (9) Health-related tasks -- As defined in CFR , specific tasks related to the needs of an individual if the individual is receiving Medicaid services from a licensed professional who may delegate or assign the health-related task to an attendant, or the health related task is exempt from delegation under (e) Texas Government Code or 22 Texas Administrative Code, Health-related tasks include tasks delegated by a registered nurse, health maintenance activities, and extension of therapy. (10) Home and Community Support Services Agency (HCSSA) -- Home and community support services agency licensed by the Department of Aging and Disability Services in accordance with Texas Health and Safety Code, Chapter 142. (11) Instrumental activities of daily living (IADLs) -- As defined in CFR , activities related to living independently in the community including, but not limited to, meal planning and preparation, managing finances, shopping for food, clothing, and other essential items, performing essential household chores, communicating by phone or other media, traveling around and participating in the community. (12) Legally authorized representative (LAR)-- A person authorized by law to act on behalf of an individual with regard to a matter described in this chapter, and may include a parent, guardian, or managing conservator of a minor, or the guardian of an adult. (13) Local Authority (LA) -- An entity designated by the Department of Aging and Disability Services in accordance with the Texas Health and Safety Code, (a). (14) Managed Care Organization (MCO) -- An organization contracted with the Health and Human Services Commission (HHSC) in accordance with of this Title. (15) Person-centered Planning -- Service planning process that is driven by the individual. Participation may include social supports chosen by the individual. RULE Eligibility (a) To be eligible for the CFC benefit, an individual must: (1) Be eligible for medical assistance under the state plan; (2) As determined annually, be in an eligibility group under the state plan that includes nursing facility services; and (3) Receive a determination, at least annually, that in the absence of the home and community-based personal assistance services and supports, the individual would otherwise require the level of care furnished in a hospital, a nursing facility, an intermediate care facility for individuals with intellectual disabilities or a related

3 condition, an institution providing psychiatric services for individuals under age 21, or an institution for mental diseases for individuals age 65 or over, if the cost could be reimbursed under the state plan. The state may permanently waive the annual recertification requirement for an individual if: (A) It is determined there is no reasonable expectation of improvement or significant change in the individual's condition; and (B) The state retains documentation of the reason for waiving the annual recertification requirement. (b) Individuals who qualify for medical assistance under the special home and communitybased waiver eligibility group defined at section 1902(a)(10)(A)(ii)(VI) of the act must meet all section 1915(c) requirements and receive at least one home and community-based service per month. RULE Assessment (a) Level of care (LOC) assessment. Individuals receive an assessment of institutional level of care prior to receiving CFC services. LOC assessments are conducted by HHSC designated entities. Texas utilizes existing LOC assessment tools for all institutional LOC eligibility determinations for implementation of CFC benefits as outlined in 354.xx of this Division. (b) Functional needs assessment. Face-to-face assessments of an individual s functional needs, strengths, preferences, and goals for CFC services and supports are provided annually. Functional needs assessments are performed by HHSC designated entities. (c) Requirements on entities conducting the assessments. Individuals or entities conducting the assessment of functional need and person-centered service plan development process are not: (1) Related by blood or marriage to the individual, or to any paid caregiver of the individual. (2) Financially responsible for the individual. (3) Empowered to make financial or health-related decisions on behalf of the individual. (4) Individuals who would benefit financially from the provision of assessed needs and services. (5) Providers of state plan home and community-based services (HCBS) for the individual, or those who have an interest in or are employed by a provider of state plan HCBS for the individual, except when HHSC determines that the only willing and qualified entity/entities to perform assessments of functional need and develop person-centered service plans in a geographic area.

4 RULE Benefits and Limitations (a) Subject to the specifications, conditions, requirements, and limitations established by the Texas Health and Human Services Commission (HHSC) or its designee, CFC services are covered subject to provisions in 42 CFR through Services include: (1) CFC Personal Assistance Services. Personal assistance services provide assistance to an individual in performing the ADLs and IADLs based on the person-centered service plan. CFC personal assistance services include: (A) Non skilled assistance with the performance of the ADLs and IADLs; (B) Household chores necessary to maintain the home in a clean, sanitary, and safe environment; and (C) Escort services, which consist of accompanying, but not transporting, and assisting an individual to access personal assistance services or activities in the community. (D) Assistance with health-related tasks as defined in 42 CFR if the individual is receiving Medicaid services from a licensed professional who may delegate or assign the health-related task to an attendant, or the health related task is exempt from delegation under (e) Texas Government Code or 22 Texas Administrative Code, Health-related tasks include tasks delegated by a registered nurse, health maintenance activities, and extension of therapy. (2) CFC Habilitation. Acquisition, maintenance, and enhancement of skills necessary for the individual to accomplish ADLs, IADLs, and health-related tasks as defined in 42 CFR CFC habilitation is provided to allow an individual to reside successfully in a community setting by assisting the individual to acquire, retain, and improve self-help, socialization, and daily living skills or assisting with and training the individual on ADLs and IADLs. Personal assistance may be a component of CFC habilitation for some individuals ADLs. CFC habilitation services include habilitation training, which is interacting face-to-face with an individual who is awake, to train the individual in activities such as: (A) Self-care; (B) Personal hygiene; (C) Household tasks; (D) Mobility; (E) Money management; (F) Community integration;

5 (G) Use of adaptive equipment; (H) Management of caregivers; (I) Personal decision making; (J) Interpersonal communication; (K) Reduction of challenging behaviors; (L) Socialization and the development of relationships; (M) Participating in leisure and recreational activities; (N) Use of natural supports and typical community services available to the public; (O) Self-administration of medication; and (P) Strategies to restore or compensate for reduced cognitive skills. (3) CFC Emergency Response Services. Back-up systems and supports including electronic devices with a backup support plan to ensure continuity of services and supports. Services are available for individuals who live alone, who are alone for significant parts of the day, or have no regular caregiver for extended periods of time, and who would otherwise require extensive routine supervision. (4) CFC Support Consultation Services. An optional service offered to individuals using the consumer directed services option. Support consultation is a voluntary service that offers practical skills training and assistance related to recruiting, screening, hiring, managing, and dismissing attendants. (b) These benefits can only be delivered in a home and community-based setting. These settings do not include: (1) Hospitals providing long-term services, (2) Nursing homes, (3) Institutions for mental disease, (4) Intermediate care facilities for individuals with an intellectual disability or related condition, or (5) Settings with the characteristics of an institution. (c) Individuals receiving services through CFC will not be precluded from receiving other home and community-based long-term services and supports through other Medicaid state plan, waiver, grant, or demonstration authorities. RULE Provider Criteria

6 CFC services are provided by long-term services and supports (LTSS) providers that are determined to be qualified by HHSC in an existing LTSS program. HHSC ensures that all current qualification standards are maintained. Providers delivering CFC services include licensed home and community support services agencies (HCSSAs), certified Home and Community-based Services (HCS) and Texas Home Living (TxHmL) providers, licensed personal emergency response services agencies, qualified financial management services agencies, and qualified support advisors. RULE Consumer Directed Services Individuals utilizing the CFC benefit may choose the Consumer Directed Services option. Rules governing the operation of CDS are in accordance with 40 TAC Chapter 41.