(spa)(tx-10-001)(approval-document)Texas Medicaid SPA TX-10-001: Approval Document (approved April 27, 2010, effective January 1, 2010)#
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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 307 Young Street, Room 833 Dallas, Texas 75202 c s GE'NTE/ PSfoiMEO1G4JPEc MED/CA/ DSERY/CfS Division of Medicaid & Children's Health, Region VI Apri127, 2010 Our Reference: SPA TX 10-001 Mr. Billy Millwee Associate Commissioner for Medicaid & CHIP Health and Human Services Commission Post Office Box l 3247 N[ail Code: H 1 Oi Austin, Texas 78711 Dear Mr. Millwee: We have reviewed the State's proposed amendment to the Texas State Plan submitted und"er Transrnittal Number 10-001, dated February 2, 2010. This amendment clarifies the eligibility criteria for exter. dd IVedicaid benefits under Section 1925 of the Act for Transitional Medical Assistance TMA), rd provides assurance that the state will collect and report information on the aer• age monthly enroliment and average monthly participation rates for adults and children covered uder TiIA, as required by Section 1925(g) of the Act in accordance with the Recovery Act. Additionally, please note that when the State submits a State Plan Amendment (SPA) that may impact Indians or Indian health providers, CMS will look for evidence of the State's Tribal consultation ,rocess for that SP. Pursuant to the new section 1902(a)( 73) of the Act added by sectiori CG 6(} aY ttie American Recovery and Reinvestrrient Act (ARRA) of 2009, the State rriust subrtiit evide,lce t CM5 regarding the solicitation of advice prior to submission of the 5tat Plan mendinent. 5uch consultation must include all federally-recognized tribes, Indian Eealth Service and lJran hldian Organizations w the State. Based on the information submitted, we have approved the amendment for incorporation into the official Texas State Plan with an effective date change of January 1, 2010. A copy of the CMS- 179 and the appraved plan pages are enclosed with this letter. If you have ariy qeestions, please contct Ford .. Blunt at (214) 767-6381. Bill Brooks Associate Regional Administrator Enclosures cc: Emily Zalkovsky, Policy Development Support
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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE AND MEDICAID SERVICES TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE AND MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Circle One): 1. TRANSMITTAL NUMBER: 10-001 FORM APPROVED OMB NO. 0938-0193 2. STATE: TEXAS 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED EFFECTIVE DATE: 1, 2010 NEW STATE PLAN AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT COMPETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT Se arate Transmittal for each amendment 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: SEE ATTACHMENT 42 CFR §435.112; a. FFY 2010 $ 00 Sections 1902(a)( 52), 1902(e)( 1), and 1925 of the Act b. FFY 2011 $ 00 c. FFY 2012 $ 00 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (IfApplicab/e): SEE ATTACHMENT SEE ATTACHMENT 10. SUBJECT OF AMENDMENT: The proposed amendment clarifies the eligibility criteria for extended Medicaid benefits under Section 1931 of the Act, or Transitional Medical Assistance (TMA). The amendment also provides assurance that the state will collect and report information on the average monthly enrollment and average monthly participation rates for adults and children covered under TMA, as required by Section 1925(g) of the Act. 11. GOVERNOR'S REVIEW (Check One): GOVERNOR'S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED: Sent to Govemor's Office this date. Comments, if any, will be forwarded upon receipt. COMMENTS OF GOVERNOR'S OFFICE ENCLOSED NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNAT AL: 16. RETURN TO: Billy Millwee 13. TYPED NA E: State Medicaid Director Post Office Box 13247, MC: H-100 Bill Millwee Austin, Texas 78711-5200 14. TITLE: State Medicaid Director 15. DATE SUBMITTED: Februarv 2. 2010 2 /i FORM CMS -179 (07-92)
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Attachment to Blocks 8 and 9 to CMS Form 179 TX Transmittal No. 10-001, Amendment No. 894 Number of the Plan Section or Attachment Supplement 15 to Attachment 2.6- A Page 1 — New ' cP Number of the Suaerseded Plan Section or Attachment Supplement 15 to Attachment 2.6- A N/A
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r- — fia,fi t° 1GS -------.. Y. k r bAl .'„...? z - .. Revision: CMS-10 ,j Ii ti' J n '' State of Texas October 2009 ,- , '" S pplement 15 to Attachment 2.6- A OMB No.: 0938-1 , . , Page 1 1i. a'c .=' C_iW+ti SiQy'x\ MtNFrnwus.. w. vn. vaMsd*' a's m. STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM State: TEXAS ELIGIBILITY UNDER SECTION 1925 OF THE ACT TRANSITIONAL MEDICAL ASSISTANCE The State cover: low-inc: crne families and children for Transitional Medical Assistance (TMA) under section 1925 of the Social Security Act (the Act). This coverage is provided for families who no longer qualify under section 1931 of the Act due to increased earned income, or working hours, from the caretaker relative's employment, or due to the loss of a time-limited earned income disregard. (42 CFR 435.112, 1902(a)( 52), 1902(e)( 1), and 1925 of the Act) " The amount, duration, and scope of services for this coverage are specified in Section 3.5 of this State plan. For Medicaid eligibility to be extended through TMA, families must have been Medicaid eligible under section 1931 (months of retroactive eligibility may be used to meet this requirement): During at leat 3 of the 6 months immediately preceding the month in which the family becarn inaligibl under sectior 1931. J For fewr than 3 of the G previous months irnmediately preceding the month in which the family became ineligible under section 1931. Specify: The State exterd:, Nleicai eliyibility urder TMA for an initial period of: 6 months. For TMA eligibility to continue into a second 6- month extension period, the arnily mut met Lhe reporting, technical, and income eligibility requirements specified 3t section 1925() of tte Act. 12 rnos ':hs. Section 1925(b) doe not apply for a second 6- month extension period. The State collects and reports participation information to the Department of Health and Human Seivices as required by section 1925(g) of the Act, in accordance with the format, timing, and frequency specified by the Secretary and makes such information publicly available. , TN No. _ - 6/_ ___ Approval Date ' oZ,7 ' V Effective Date ' ' Supersedes T'N No. :+= ` ' `'
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Marks, Marsha L. (CMS/SC) From: Sent: To: Cc: Subject: Attachments See Attached. State: Texas Marks, Marsha L. (CMS/SC) Monday, May 03, 2010 9:14 AM CMS CMSO 508 SPA Blunt, Ford J. (CMS/SC); Prisby, Karen L. (CMS/CMCHO); Seng, Suzette (CMS/SC) Approval Pkg for TX 10-01 TX1001APPROVAL.doc; Final Approval Pkg for TX 10-01. pdf Brief Description: The amendment clarifies the eligibility criteria for extending Medicaid benefits under Section 1925 of Transitional Medical Assistance (TMA) and provides assurance that the state will be collect and report information on the average monthly enrollment and average monthly participation rates for adults and children covered under the TMA. This SPA does not have a direct impact on Indians, Indian health programs, or Urban Indian organizations. Approval Date: 4/ 27/ 2010 Effective Date: 1/1/ 2010 r irk i`; t - Itl & ( n! rvi '- ;;; rs cr vd= r ; i rr s = s ,,..< .. g , c;,; E r( .} i is cr ' Yi, i illr 3r' Nlt Or l T;s 2 I`i 21-7 r %;' . 6=x -";'7-; ; .., marsha.marks( acros. hhs.gov
(spa)(tx-13-022)(approval-document)Texas Medicaid SPA TX-13-022: Approval Document (approved August 28, 2013, effective April 1, 2013)#
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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Dallas Regional Office 1301 Young Street, Suite 833 Dallas, Texas 75202
DIVISION OF MEDICAID & CHILDREN’S HEALTH - REGION VI
August 28, 2013
Our Reference: SPA TX 13-022
Ms. Kay Ghahremani State Medicaid Director Health and Human Services Commission Post Office Box 13247 Mail Code H100 Austin, Texas 78711
Dear Ms. Ghahremani:
We have reviewed the State’s proposed amendment to the Texas State Plan submitted under Transmittal Number 13-22, dated June 28, 2013. This state plan amendment updates the Medicaid payments for dental services provided under the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program for fee for service dental claims.
Based on the information submitted, we have approved the amendment for incorporation into the official Texas State Plan with an effective date change of April 1, 2013. A copy of the CMS-179 and approved plan pages are enclosed with this letter.
If you have questions, please contact Cheryl Rupley at (214) 767-6278.
Sincerely,
Bill Brooks
Associate Regional Administrator
cc: Becky Brownlee, Policy Development Support Digitally signed by Billy D. Brooks -S DN: c=US, o=U.S. Government, ou=HHS, ou=CMS, ou=People, 0.9.2342.19200300.100.1.1=2000039050, cn=Billy D. Brooks -S Date: 2013.09.03 15:27:08 -05'00'
(spa)(tx-13-022)(attachment)Texas Medicaid SPA TX-13-022: Attachment (approved August 28, 2013, effective April 1, 2013)#
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State of Texas Attachment 4.19-B Page 25k.1 32. Reimbursement Methodologies for Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services - continued 13) Dental services reimbursable only for Medicaid-eligible clients under age 21 include those provided by independently enrolled dentists who are reimbursed according to the lesser of the provider's billed charges or fees determined by the Texas Health and Human Services Commission (HHSC). These are access- based fees under Item one of Attachment 4.19-B, relating to the reimbursement methodology for physicians and certain other practitioners. (a) All fee schedules are available through the agency's website as outlined on Attachment 4.19-B, page 1. (b) The agency's fee schedule was revised with new fees for EPSDT dental services effective April 1, 2013. The fee schedule was posted on the agency website on April 5, 2013. TN: Approval Date: Effective Date: Supersedes TN: 13-22 13-10 8/28/13 State: Texas Date Received: 28 June, 2013 Date Approved: 28 August, 2013 Date Effective: 1 April, 2013 Transmittal Number: TX 13-22 4/1/13
(spa)(tx-13-022)(form-cms-179)Texas Medicaid SPA TX-13-022: Form CMS-179 (approved August 28, 2013, effective April 1, 2013)#
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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES FORM APPROVED OMB NO. 0938-0193 1. TRANSMITTAL NUMBER: 2. STATE: TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL 13-022 TEXAS FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE: CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES April 1, 2013 5. TYPE OF PLAN MATERIAL (Circle One): q NEW STATE PLAN q AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: SEE ATTACHMENT 42 CFR §§ 440.40, 441.56(b)(vi); §1905(r)(3) of Social Security a. FFY 2013 $(327,005) Act, relating to Early and Periodic Screening, Diagnosis and b. FFY 2014 $(693,905) Treatment. c. FFY 2015 $(738,183) 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): SEE ATTACHMENT TO BLOCKS 8 & 9 SEE ATTACHMENT TO BLOCKS 8 & 9 10. SUBJECT OF AMENDMENT: The proposed amendment updates the Medicaid fee schedule for the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program for fee-for-service dental claims. 11. GOVERNOR'S REVIEW (Check One): q GOVERNOR'S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED: q COMMENTS OF GOVERNOR'S OFFICE ENCLOSED Sent to Governor's Office this date. Comments, if any, will q N REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 10 be forwarded upon receipt. 12. SI URE OF AGE Y OFFICIAL: 16. RETURN TO: Kay Ghahremani 13. TYPED NAME: State Medicaid Director Kay Ghahremani PO Box 13247 MC H-100 Austin, Texas 78711 14. TITLE: State Medicaid Director 15. DATE SUBMITTED July 2, 2013 FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: 18. DATE APPROVED: PLAN APPROVED - O NE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 20. SIGNATURE OF REGIONAL OFFICIAL: 21. TYPED NAME: 22. TITLE: 23. REMARKS: FORM CMS - 179 (07-92) 28 June, 2013 Bill Brooks Associate Regional Administrator Division of Medicaid & Children's Health 28 August, 2013 1 April, 2013 Digitally signed by Billy D. Brooks -S DN: c=US, o=U.S. Government, ou=HHS, ou=CMS, ou=People, 0.9.2342.19200300.100.1.1=2000039050, cn=Billy D. Brooks -S Date: 2013.09.03 15:28:10 -05'00'
(spa)(tx-13-28)(approval-document)Texas Medicaid SPA TX-13-28: Approval Document (approved December 3, 2013, effective July 1, 2013)#
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Table of Contents
State/Territory Name: Texas State Plan Amendment (SPA) #: 13-28 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Superseding Page List 4) Approved SPA Pages
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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Dallas Regional Office 1301 Young Street, Suite 833 Dallas, Texas 75202
DIVISION OF MEDICAID & CHILDREN’S HEALTH - REGION VI
December 3, 2013
Our Reference: SPA TX 13-028
Ms. Kay Ghahremani State Medicaid/CHIP Director Health and Human Services Commission Post Office Box 13247 Mail Code H100 Austin, Texas 78711
Dear Ms. Ghahremani:
We have reviewed the State’s proposed amendment to the Texas State Plan submitted under Transmittal Number 13-28, dated September 30, 2013. This state plan amendment updates the chemical dependency treatment facility services fee schedule.
Based on the information submitted, we have approved the amendment for incorporation into the official Texas State Plan with an effective date change of July 1, 2013. A copy of the CMS-179 and approved plan pages are enclosed with this letter.
If you have questions, please contact Cheryl Rupley at (214) 767-6278.
Sincerely,
Bill Brooks
Associate Regional Administrator
cc: Becky Brownlee, Policy Development Support /s/
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TX Redacted SPAs Page 2
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Attachment to Blocks 8 & 9 of CMS Form 179
Transmittal Number 13-028
Number of the Number of the Superseded Plan Section or Attachment Plan Section or Attachment Attachment 4.19-B Attachment 4.19-B
Page 21 Page 21 (TN 11-22)
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State: Texas Date Received: 30 September, 2013 Date Approved: 3 December, 2013 Effective Date: 1 July, 2013 Transmittal Number: TX 13-28 13-28 11-22 12/3/13 7/1/13
(spa)(tx-13-32)(approval-document)Texas Medicaid SPA TX-13-32: Approval Document (approved April 2, 2014, effective July 1, 2013)#
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Table of Contents
State/Territory Name: Texas State Plan Amendment (SPA) #: 13-32 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved SPA Pages
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DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services Dallas Regional Office M 1301 Young Street, Suite 833 Pn.
2
2 CONSORTIUM FOR MEDICA! & CHILDREN’S HEALTH OPERATIONS
Dallas, Texas 7
DIVISION OF MEDICAID & CHILDREN’S HEALTH _- REGION VI
April 2, 2014 Our Reference: SPA TX 13-032
Ms. Kay Ghahremani
State Medicaid Director
Health and Human Services Commission Post Office Box 13247
Mail Code H100
Austin, Texas 78711
Dear Ms. Ghahremani:
We have reviewed the State’s proposed amendment to the Texas State Plan submitted under Transmittal Number 13-32, dated September 30, 2013. This state plan amendment updates the fee schedule for dental services under the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program.
Based on the information submitted, we have approved the amendment for incorporation into the official Texas State Plan with an effective date change of July 1, 2013. A copy of the CMS-179 and approved plan pages are enclosed with this letter.
If you have questions, please contact Cheryl Rupley at (214) 767-6278.
Sincerely,
Bill Brooks Associate Regional Administrator
ce: Becky Brownlee, Policy Development Support
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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES
FORM APPROVED OMB NO. 0938-0193
TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES
1. TRANSMITTAL NUMBER:
13-032
2. STATE: TEXAS
3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID)
TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE & MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES
4. PROPOSED EFFECTIVE DATE:
July 1, 2013
5. TYPE OF PLAN MATERIAL (Circle One): O O
AMENDMENT TO BE CONSIDERED AS NEW PLAN
AMENDMENT
COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment)
6. FEDERAL STATUTE/REGULATION CITATION:
42 CFR 440.40; and 441.56; §1905(r) of Social Security Act, relating to Early and Periodic Screening, Diagnosis and Treatment.
7. FEDERAL BUDGET IMPACT: SEE ATTACHMENT
a. FFY 2013 $ (944,038) b. FFY 2014 $ (4,001,677) c. FFY 2015 $ (4,242,481)
8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:
SEE ATTACHMENT TO BLOCKS 8 &9
9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (/f Applicable):
SEE ATTACHMENT TO BLOCKS 8 &9
10. SUBJECT OF AMENDMENT:
(EPSDT) program dental fee schedule.
The proposed amendment updates the Medicaid fee schedule for the Early and Periodic Screening, Diagnosis and Treatment
11. GOVERNOR'S REVIEW (Check One):
13. TYPED : Kay Ghahremani
14. TITLE: State Medicaid Director
15. DATE SUBMITTED September 30, 2013
Oo GOVERNOR'S OFFICE REPORTED NO COMMENT i} OTHER, AS SPECIFIED: oO COMMENTS OF GOVERNOR'S OFFICE ENCLOSED Sent to Governor's Office this date. Comments, if any, will O NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL _ be forwarded upon receipt. 12. SI 16. RETURN TO: Kay Ghahremani
State Medicaid Director PO Box 13247 MC H-100 Austin, Texas 78711
FOR REGIONAL OFFICE USE ONLY
17. DATE RECEIVED:
30 September, 2013
18. DATE APPROVED:
2 April, 2014
PLAN APPROVED — ONE COPY ATTACHED
19. EFFECTIVE DATE OF APPROVED MATERIAL: 1 July, 2013
21. TYPED NAME: BILL RROOKS
22. TITLE: Associate Regional Administrat Division of Medicaid & Children's Hea
or th
3. REMARKS:
FORM CMS — 179 (07-92)
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State: Texas Date Received: 30 September, 2013 Date Approved 2 April, 2014 Date Effective: 1 July, 2013 Transmittal Number: TX 13-32
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State: Texas Date Received: 30 September, 2013 Date Approved 2 April, 2014 Date Effective: 1 July, 2013 Transmittal Number: TX 13-32 13-32 13-22 4/2/14 7/1/13
(spa)(tx-13-45-mm2)(approval-document)Texas Medicaid SPA TX-13-45-MM2: Approval Document (approved July 15, 2014, effective October 1, 2013)#
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Table of Contents
State/Territory Name: Texas State Plan Amendment (SPA) #: 13-45 MM2 This file contains the following documents in the order listed: 1) Approval Letter 2) Additional Companion letter 3) CMS 179 Form/Summary Form 4) Approved SPA Pages
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DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Dallas Regional Office G & 1301 Young Street, Suite 833
CENTERS FOR MEDICARE & MEDICAID SERVICES Dallas, Texas 75202 aaamaimaia tae hehe & CHILDREN’S HEALTH OPERATIONS
DIVISION OF MEDICAID & CHILDREN’S HEALTH _- REGION VI
July 15, 2014 Our Reference: SPA TX 13-0045-MM2
Ms. Kay Ghahremani
State Medicaid Director
Health and Human Services Commission Post Office Box 13247
Mail Code H100
Austin, Texas 78711
Dear Ms. Ghahremani:
We have reviewed the State’s proposed amendment to the Texas State Plan submitted under Transmittal Number 13-0045-MM2. Based upon a review of the changes submitted on July 9, 2014, we have approved the amendment for incorporation into the official Texas State Plan with an effective date of October |, 2013.
Enclosed is an approved copy of Texas’s state plan amendment (SPA) 13-0045-MM2, which was originally submitted to CMS on December 31, 2013. SPA 13-0045-MM2 incorporates the MAGI- based eligibility process requirements, including the single streamlined application, into Texas’s Medicaid state plan in accordance with the Affordable Care Act.
Texas is using interim alternative single streamlined paper and online applications. By August 31, 2014, the state will implement a revised alternative single streamlined paper application and by December 31, 2014, Texas will implement a revised alternative single streamlined online application. Both revised applications will address CMS concerns outlined in the companion letter issued with this SPA approval.
Enclosed is a copy of the following S94 state plan pages and attachments to be incorporated within a separate section at the end of Texas’s approved state plan:
e $94, pages $94-1 and S94-2 e Attachment | — Use of the Alternative Single Streamlined Paper Application e Attachment 2 — Use of the Alternative Single Streamlined Online Application
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CMS appreciates the significant amount of work your staff dedicated to preparing this state plan amendment. We continue to be available to provide technical assistance. If you have any questions about your application, please contact Dena Greenblum at Dena.Greenblum@cms.hhs. gov.
If you have any questions about this letter or need any additional information, please contact Cheryl Rupley at (214) 767-6278.
Sincerely,
Bill Brooks Associate Regional Administrator
ce: Becky Brownlee, Policy Development Support
(spa)(tx-13-45-mm2)(approval-document)(page-4)Page 4#
DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Dallas Regional Office G & 1301 Young Street, Suite 833
Dallas, Texas 75202
DIVISION OF MEDICAID & CHILDREN’S HEALTH _- REGION VI
CENTERS FOR MEDICARE & MEDICAID SERVICES CONSORTIUM FOR MEDICAID & CHILDREN’S HEALTH OPERATIONS
July 15, 2014 Our Reference: SPA TX 13-0045-MM2
Ms. Kay Ghahremani
State Medicaid Director
Health and Human Services Commission Post Office Box 13247
Mail Code H100
Austin, Texas 78711
Dear Ms. Ghahremani:
This letter is being sent as a companion to Centers for Medicare &
Medicaid Services (CMS)
approval of state plan amendment (SPA) 13-0045-MM2, which was submitted to CMS on December 31, 2013. Our review of this submission included a review of the alternative single
streamlined paper and online applications developed by the state.
Until December 31, 2014 the state is using an interim alternative single streamlined online application. By December 31, 2014, the state will implement a revised online application to reflect
the following changes:
Alternative Single Streamlined Online Application Necessary changes: Completion Date 1. Ifa household member is not applying for coverage, questions on citizenship, immigration status, foster care, residency, and December 31, 2014 disability/special health needs will not appear. 2. Add language to clarify that provision of an SSN is optional for December 31, 2014 non-applicant household members. 3. Remove detailed questions about absent parents, beyond December 31, 2014 identification of whether or not there is an absent parent. 4. Remove income instructions that direct applicants to include child support and money from family and friends in expected December 31, 2014 income.
(spa)(tx-13-45-mm2)(approval-document)(page-5)Page 5#
5. Remove all asset questions from the MAGI-based application. August 31, 2014
6. Remove all questions related to disregards not countable under MAGI from the MAGI-based application (such as costs to take | December 31, 2014 care of others).
7. Remove requests for documentation of information that can be verified electronically by the state, unless the state has December 31, 2014 attempted to verify electronically and failed.
Until August 31, 2014 the state is using an interim alternative single streamlined paper application. By August 31, 2014, the state will implement a revised paper application to reflect the following changes:
Alternative Single Streamlined Paper Application
Necessary changes: Completion Date
1. Remove all questions regarding assets (Step 3). August 31, 2014
2. Remove detailed questions about absent parents, beyond
ye . - 7 20 identification of whether or not there is an absent parent. August 31, 2014
Please submit the revised alternative single streamlined paper application to CMS for review no later than August 1, 2014, and please submit the revised alternative single streamlined online application to CMS for review no later than December 1, 2014. This will allow time for review prior to the agreed upon implementation date. The revised applications may be emailed to the RO SPA mailbox at CMS SPA_Waivers_Dallas_R06, referencing SPA 13-0045-MM2. A new SPA
submission is not required.
We continue to be available to provide technical assistance. If you have any questions about your application, please contact Dena Greenblum at Dena.Greenblum@cms.hhs. gov.
If you have any questions about this letter or need any additional information, please contact Cheryl Rupley at (214) 767-6278.
Sincerely,
Bill Brooks Associate Regional Administrator Division of Medicaid and Children’s Health Operations
ce: Becky Brownlee, Policy Development Support
(spa)(tx-13-45-mm2)(approval-document)(page-6)Page 6#
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Medicaid S'
Eligibility
__ 1K.0719,R00.00 - Oct 01, 2013 Home Logout Finder Save Validate Print Help_
Control Panel
Medicaid State Plan Eligibility: Summary Page (CMS 179)
General Information
State/Territory name Texas Transmittal Number:
File Management
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Summary (CMS179) Tt
Proposed Effective Date
4010172013
Federal Statute/Regulation Citation
42 CFR 435, Subpart J anc
part M, 42 CFR 43
Federal Budget Impact
Federal Fiscal Year| Amount
First Year 2014
Second Year 2015
Subject of Amendment
Governor's Office Review Governor's office reported no comment
Comments of Governor's office received Describe
No reply received within 45 days of submittal
Other, as specified Describe
(spa)(tx-13-45-mm2)(approval-document)(page-7)Page 7#
Signature of State Agency Official
Submitted By Ashley Fox Last Revision Date Jul 9, 2014 Submit Date Dec 31, 2013
BACK CONTINUE
Date Received: 12/31/2013
Date Approved: 07/15/2014
Signature of Regional Official:
PRINTED NAME and Title: Bill Brooks, Associate Regional Administrator
Division of Medicaid and Children's Health
(spa)(tx-13-45-mm2)(approval-document)(page-8)Page 8#
USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATION
Paper Application Online Application
TRANSMITTAL NUMBER:
TX-13-0045-MM2
STATE:
Texas
Through August 31, 2014, the state is using an interim paper alternative single streamlined application. After August 31, 2014, the state will use a revised paper application. The revised application will address the issues outlined in the CMS letter, which was issued with the approval of this state plan amendment, concerning the state’s application. The revised application will be incorporated by reference into the state plan. ___________________________________________________________________________ TN No: 13-0045-MM2 APPROVAL DATE:07/15/2014 EFFECTIVE DATE: 10/1/2013 STATE: TEXAS
PAGE: Attachment 1 State: Texas Date Received: 12/31/2013 Date Approved: 07/15/2014 Date Effective: 10/1/2013 Transmittal Number: 13-0045-MM2
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USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATION
Paper Application Online Application
TRANSMITTAL NUMBER:
TX-13-0045-MM2
STATE:
Texas
Through December 31, 2014, the state is using an interim alternative single streamlined application. After December 31, 2014, the state will use a revised alternative single streamlined application. The revised application will address the issues outlined in the CMS letter, which was issued with the approval of this state plan amendment, concerning the state’s application. The revised application will be incorporated by reference into the state plan.
State: Texas Date Received: 12/31/2013 Date Approved: 07/15/2014 Date Effective: 10/1/2013 Transmittal Number: 13-0045-MM2 ___________________________________________________________________________ TN No: 13-0045-MM2 APPROVAL DATE: 07/15/2014 EFFECTIVE DATE: 10/1/2013 STATE: TEXAS
PAGE: Attachment 2
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TX 13-045 Page 2
State: Texas Date Received: 12/31/2013 Date Approved: 07/15/2014 Date Effective: 10/01/2013 Transmittal Number: 13-0045-MM2 ___________________________________________________________________________ TN No: 13-0045-MM2 APPROVAL DATE: 10/01/2013 EFFECTIVE DATE: 10/1/2013 STATE: TEXAS
PAGE: S94 Page 1
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TX 13-045 Page 3
State: Texas Date Received: 12/31/2013 Date Approved: 07/15/2014 Date Effective: 10/01/2013 Transmittal Number: 13-0045-MM2 ___________________________________________________________________________ TN No: 13-0045-MM2 APPROVAL DATE: 07/15/2014
EFFECTIVE DATE: 10/1/2013 STATE: TEXAS
PAGE: S94 Page 2
(spa)(tx-13-51)(approval-document)Texas Medicaid SPA TX-13-51: Approval Document (approved May 9, 2014, effective December 31, 2013)#
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Table of Contents
State/Territory Name: Texas State Plan Amendment (SPA) #: 13-51 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Superseding Page List 4) Approved SPA Page
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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services
Dallas Regional Office
1301 Young Street, Suite 833
Dallas, Texas 75202
CMS
CENTERS FOR MEDICARE & MEDICAID SERVICES CONSORTIUM FOR MEDICAID & CHILDREN’S HEALTH OPERATIONS
DIVISION OF MEDICAID & CHILDREN’S HEALTH _- REGION VI
May 9, 2014 Our Reference: SPA TX 13-051
Ms. Kay Ghahremani
State Medicaid/CHIP Director
Health and Human Services Commission Post Office Box 13247
Mail Code H100
Austin, Texas 78711
Dear Ms. Ghahremani:
We have reviewed the State’s proposed amendment to the Texas State Plan submitted under Transmittal Number 13-51, dated December 26, 2013. This state plan amendment disregards all income when considering eligibility for children under age 21 for whom the Texas Department of Family and Protective Services (TDFPS) assumes financial responsibility in whole or in part or who are under the age of 18 and are in the managing conservatorship of TDFPS.
Based on the information submitted, we have approved the amendment for incorporation into the official Texas State Plan with an effective date change of December 31, 2013. A copy of the CMS-179 and approved plan pages are enclosed with this letter.
If you have questions, please contact Cheryl Rupley at (214) 767-6278.
ce: Becky Brownlee, Policy Development Support
Sincerely,
Bill Brooks Associate Regional Administrator
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DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE AND MEDICAID SERVICES OMB NO. 0938-0193. 1. TRANSMITTAL NUMBER: 2. STATE: TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL 13-051 TEXAS FOR: CENTERS FOR MEDICARE AND MEDICAID SERVICES
3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID)
TO: REGIONAL ADMINISTRATOR
CENTERS FOR MEDICARE AND MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES
4. PROPOSED EFFECTIVE DATE:
December 31, 2013
5. TYPE OF PLAN MATERIAL (Circle One):
Oo
NEW STATE PLAN
(1 __ AMENDMENT TO BE CONSIDERED AS NEW PLAN
Kl AMENDMENT
COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment)
6. FEDERAL STATUTE/REGULATION CITATION: 42 CFR §435.222 Section 1902(r)(2) of the Act
7. FEDERAL BUDGET IMPACT: SEE ATTACHMENT
a. FFY 2014 $1,991,124 b. FFY 2015 $2,810,107 c. FFY 2016 $2,997,815
8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:
SEE ATTACHMENT TO BLOCKS 8 &9
9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (/f Applicable):
SEE ATTACHMENT TO BLOCKS 8 &9
10. SUBJECT OF AMENDMENT:
Disregards all income when considering eligibility for children under age 21 for whom the Texas Department of Family and Protective Services (TDFPS) assumes financial responsibility in whole or in part, or who are under the age of 18 and are in the managing conservatorship of TDFPS.
11. GOVERNOR'S REVIEW (Check One):
oO
o Oo
GOVERNOR'S OFFICE REPORTED NO COMMENT
COMMENTS OF GOVERNOR'S OFFICE ENCLOSED NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL
& OTHER, AS SPECIFIED: Sent to Governor's Office this date. Comments, if any, will be forwarded upon receipt.
12., SIGNATURE OF STATE AGENCY OFFICIAL:
14. TITLE: State Medicaid Director
15. DATE SUBMITTED: December 20, 2013
16. RETURN TO:
Kay Ghahremani
State Medicaid Director
Post Office Box 13247, MC: H-100 Austin, Texas 78711
FOR REGIONAL OFFICE USE ONLY
17. DATE RECEIVED:
20 December, 2013
18. DATE APPROVED: May, 2014
PLAN APPROVED — ONE COPY ATTACHED
19. EFFECTIVE DATE OF APPROVED MATERIAL:
31 December, 2013
20. SIGNA IAL:
21. TYPED NAME:
Bill Brooks
22. TITLE: Associate Regional Administratd Division of Medicaid & Children's Heal
23. REMARKS:
FORM CMS - 179 (07-92)
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Attachment to Blocks 8 & 9 of CMS Form 179 Transmittal Number 13-051 Number of the Number of the Superseded Plan Section or Attachment Plan Section or Attachment Supplement 1 to Attachment 2.2-A Supplement 1 to Attachment 2.2-A Page 1 Page 1 Supplement 8a to Attachment 2.6-A Supplement 8a to Attachment 2.6-A Page 4 N/A - new page State: Texas Date Received: 12-20-13 Date Approved: 5-9-14 Date Effective: 12-31-13 Transmittal Number: 13-51
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TN: ________________ Approval Date: ________________ Effective Date: ________________
Supersedes TN: ________________ 42 CFR 435.222
Supplement 1 to Attachment 2.2-A Page 1
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State: _____________Texas_____________________
REASONABLE CLASSFICATIONS OF INDIVIDUALS UNDER THE AGE OF 21, 20, 19, AND 18
A. Individuals under 21 years of age for whom the Texas Department of Family and Protective Services (TDFPS) assumes financial responsibility, in whole or in part, and who are being cared for in:
1. Family foster homes which are licensed and monitored by TDFPS; 2. Family foster homes which are verified and monitored by licensed, public or private child-placing agencies; 3. Private 24-hour care facilities licensed by TDFPS; or 4. In a supervised setting designed for independent living for individuals 18 and older who are in extended foster care.
B. Children in the community who are under the age 18 (or under age 19 if expected to graduate by their 19th birthday and who live with relative(s)) within the Aid for Families with Dependent Children (AFDC) required degree of relationship.
C. Children under the age of 18 placed by the county or district court in the managing conservatorship of TDFPS as the result of a finding of abuse or neglect by TDFPS.
D. Children under the age of 21 who have been committed to the custody of the Texas Juvenile Justice Department.
E. Children ages 10 through 17 who are under the continuing jurisdiction of the juvenile court and who are placed in a setting such as a group home, a residential treatment facility, or a foster home which will permit children to receive Medicaid services.
F. Former foster care youth under the age of 21 who had been placed inside or outside of Texas under the Interstate Compact on the Placement of Children.
State: Texas Date Received: 12-20-13 Date Approved: 5-9-14 Date Effective: 12-31-13 Transmittal Number: 13-51 13-51 5/9/14 12/31/13 06-25
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TN: ________________ Approval Date: ________________ Effective Date: ________________
Supersedes TN: ________________ State of Texas Supplement 8a to Attachment 2.6-A Page 4
State Plan under Title XIX of the Social Security Act State: Texas
MORE LIBERAL METHODS OF TREATING INCOME UNDER SECTION 1902(r)(2) OF THE ACT
For the reasonable classifications of children covered under 42 CFR 435.222 as specified at A–F on Supplement 1 to Attachment 2.2-A, Page 1 –
In determining eligibility, disregard all income.
State: Texas Date Received: 12-20-13 Date Approved: 5-9-14 Date Effective: 12-31-13 Transmittal Number: 13-51 New Page 13-51 5/9/14 12/31/13
(spa)(tx-14-02-mm1)(approval-document)Texas Medicaid SPA TX-14-02-MM1: Approval Document (approved August 25, 2014, effective January 1, 2014)#
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_____________________________________________________________________________
Table of Contents State/Territory Name: Texas State Plan Amendment (SPA) #: 14-02 MM1 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Superseding Page Listings 4) Approved SPA Pages
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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Dallas Regional Office 1301 Young Street, Suite 833 Dallas, Texas 75202
DIVISION OF MEDICAID & CHILDREN’S HEALTH - REGION VI
August 25, 2014 Our Reference: SPA TX 14-0002 MM1 Ms. Kay Ghahremani State Medicaid/CHIP Director Health and Human Services Commission Post Office Box 13247 Mail Code H100 Austin, Texas 78711 Dear Ms. Ghahremani: We have reviewed the State’s proposed amendment to the Texas State Plan submitted under Transmittal Number 14-0002 MM1, dated March 31, 2014. This state plan amendment establishes that the State is using federally required modified adjusted gross income (MAGI) methodology for determining Medicaid eligibility criteria for children, parents and caretakers, pregnant women, and individuals under age 21 who were formerly under Texas conservatorship. The State also provides coverage for children receiving non IV-E adoption assistance and those in certain reasonable classifications for which the income test for eligibility determinations was eliminated based on state plan policies in effect before this year. The amendment also indicates that the State does not opt to cover the adult group for otherwise ineligible adults under age 65 or the groups for individuals only eligible for family planning services or tuberculosis-related services. The state plan amendment also establishes the Former Foster Care Children’s group, which provides Medicaid for former foster care children ages 18 up to 26, in accordance with Social Security Act § 1902 (a) (10) (A) (i) (IX). Based on the information submitted, we have approved the amendment for incorporation into the official Texas State Plan with an effective date change of January 1, 2014. A copy of the CMS- 179 and approved plan pages are enclosed with this letter.
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If you have questions, please contact Cheryl Rupley at (214) 767-6278. Sincerely, Bill Brooks Associate Regional Administrator cc: Becky Brownlee, Policy Development Support
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TX.0884.R00.00 - Jan 01, 2014 Page | of 2
Medicaid State Plan Eligibility: Summary Page (CMS 179)
State/Territory name: Texas
Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered.
TX-14-0002
Proposed Effective Date 01/01/2014 (mm/dd/yyyy)
Federal Statute/Regulation Citation This submission includes a large number of citations. See templates for statute/regulation citation information.
Federal Budget Impact Federal Fiscal Year Amount First Year 2014 $ 142004194.79 Second Year 2015 $ 464683540.49
Subject of Amendment The proposed amendments establish that the state is using federally required modified adjusted gross income (MAGI) methodology for determining Medicaid eligibility for children, parents and caretakers, pregnant women, and individuals under age 21 who were formerly under Texas conservatorship. The state also provides coverage for non [V-E adoption assistance and coverage to certain individuals under age 21 who are in certain reasonable classifications, which operate under a waiver that eliminates income tests for eligibility determinations.
The proposed amendments indicate that the state does not opt to provide Medicaid for childless adults under age 65, family planning services, and tuberculosis-only services.
Federal law also requires the state to establish the Former Foster Care ChildrenA fAfA,AfAfA,A, Ag AfAfA,A,AfA,A,A€AfAfA,AAfA, »A™s program, which provides Medicaid for former foster care children ages 18 to 25 who aged out of foster care while in Texas's conservatorship at age 18 or older and were receiving | Medicaid when they aged out of foster care, in accordance with Social Security Act
AfAfA, AfAfA, A, AfAfA, A sASA, A,A§1902(a)(10)(A)(i)(IX), 42 U.S AfAfA AfAfA,A,A,AfAfA,A,ASA,A,A§ 1396a(a)(10)(A)(i)(IX).
Governor's Office Review Governor's office reported no comment
Comments of Governor's office received Describe:
No reply received within 45 days of submittal ©) Other, as specified Describe: Sent to Governor's Office this date. Comments, if any, will be forwarded upon receipt.
https://wms-mmdl.cdsvde.com/MMDL/faces/protected/mac/c01/print/PrintSelector.jsp 08/26/2014
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Date Received: 31 March, 2014 Date Approved: 25 August, 2014 Date Effective 1 January, 2014 Printed Name and Title: BILL BROOKS Associate Regional Administrator Division of Medicaid & Children's Health
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1
SUPERSEDING PAGES OF STATE PLAN MATERIAL
TRANSMITTAL NUMBER: 14-0002 MM1
STATE: Texas Pages or sections of pages being superseded by S25, S28, S30, S51, S52, S53, S57, and S14 and related pages or sections of pages being deleted as obsolete
State Plan Section
Complete Pages Removed
Partial Pages Removed Attachment 2.2-A
Page 1 Page 3 Page 3a Page 4 Page 4a Page 12 Page 13 Page 13a Page 14 Page 14a Page 23 Page 23b (for independent foster care adolescents) Page 23b(1) Page 23d
Page 2, A.2.b Page 2, A.2.c Page 9, B.1 Page 9c, B.1 for pregnant women and parents/caretaker relatives Page 2a, A.3 Page 20, B.14
Supplement 1 to Attachment 2.2-A
Page 1 Page 18
Attachment 2.6-A
Page 3b Page 11a Page 19 Page 19a Page 19b Page 21
Page 1, A.2.a(i) and (iii)
Page 6 related to AFDC recipients, pregnant women, infants, and children Page 7, 1.a(1) and (2) Page 12, 1.e(2) Page 18, 5.e Page 21a, 6.e Page 25, 11.a(3) Supplement 1 to Attachment 2.6-A Page 1 Page 1a Page 2 Page 3 Page 4
State: Texas Date Received: 3/31/14 Date Approved: 8/25/14 Date Effective: 1/1/14 Transmittal Number: TX 14-0002 MM1
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2
Supplement 2 to Attachment 2.6-A
Pages 1-5
Supplement 8a to Attachment 2.6-A Page 1 Page 4 Page 1b, Related to pregnant women and children Page 3, Related to pregnant women and children Supplement 8b to Attachment 2.6-A
Page 5, Remove all groups listed except medically needy Supplement 14 to Attachment 2.6-A Pages 1 and 2
State: Texas Date Received: 3/31/14 Date Approved: 8/25/14 Date Effective: 1/1/14 Transmittal Number: TX 14-0002 MM1
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Page 1 of 7 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 AFDC Income Standards S14 Enter the AFDC Standards below. All states must enter: MAGI-equivalent AFDC Payment Standard in Effect As of May 1, 1988 and AFDC Payment Standard in Effect As of July 16, 1996 Entry of other standards is optional. MAGI-equivalent AFDC Payment Standard in Effect As of May 1, 1988 Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way Enter the standard by living arrangement Remove Living Arrangement Name of living arrangement One Parent/Caretaker Description Household size Standard ($) + 1 103 x + 2 196 x + 3 230 x + 4 277 x + 5 310 x + 6 356 x + 7 389 x + 8 441 x State: Texas Date Received: 3/31/14 Date Approved: 8/25/14 Date Effective: 1/1/14 Transmittal Number: TX 14-0002 MM1 Transmittal Number: TX 14-02 MM1 Date Approved: 8/25/14 Date Effective 1/1/14
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Page 2 of 7 Medicaid Eligibility + 9 476 x + 10 527 x + 11 562 x + 12 613 x + 13 648 x + 14 700 x + 15 734 x Additional incremental amount Yes No Increment amount $ 52 Remove Living Arrangement Name of living arrangement Two Parents/Caretakers Description Household size Standard ($) + 1 x + 2 161 x + 3 251 x + 4 285 x + 5 332 x + 6 367 x + 7 412 x + 8 447 x + 9 500 x + 10 535 x + 11 587 x + 12 622 x State: Texas Date Received: 3/31/14 Date Approved: 8/25/14 Date Effective: 1/1/14 Transmittal Number: TX 14-0002 MM1 Transmittal Number: TX 14-02 MM1 Date Approved: 8/25/14 Date Effective 1/1/14
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Page 3 of 7 Medicaid Eligibility + 13 675 x + 14 710 x + 15 762 x Additional incremental amount Yes No Increment amount $ 52 Add Living Arrangement The dollar amounts increase automatically each year Yes No AFDC Payment Standard in Effect As of July 16, 1996 Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way Enter the standard by living arrangement Remove Living Arrangement Name of living arrangement One Parent/Careaker Description Household size Standard ($) + 1 78 x + 2 163 x + 3 188 x + 4 226 x + 5 251 x State: Texas Date Received: 3/31/14 Date Approved: 8/25/14 Date Effective: 1/1/14 Transmittal Number: TX 14-0002 MM1 Transmittal Number: TX 14-02 MM1 Date Approved: 8/25/14 Date Effective 1/1/14
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Page 4 of 7 Medicaid Eligibility + 6 288 x + 7 313 x + 8 356 x + 9 382 x + 10 425 x + 11 451 x + 12 494 x + 13 520 x + 14 563 x + 15 589 x Additional incremental amount Yes No Increment amount $ 43 Remove Living Arrangement Name of living arrangement Two Parents/Caretakers Description Household size Standard ($) + 1 x + 2 125 x + 3 206 x + 4 231 x + 5 268 x + 6 294 x + 7 330 x + 8 356 x + 9 399 x State: Texas Date Received: 3/31/14 Date Approved: 8/25/14 Date Effective: 1/1/14 Transmittal Number: TX 14-0002 MM1 Transmittal Number: TX 14-02 MM1 Date Approved: 8/25/14 Date Effective 1/1/14
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Page 5 of 7 Medicaid Eligibility + 10 425 x + 11 468 x + 12 494 x + 13 537 x + 14 563 x + 15 606 x Additional incremental amount Yes No Increment amount $ 43 Add Living Arrangement The dollar amounts increase automatically each year Yes No MAGI-equivalent AFDC Payment Standard in Effect As of July 16, 1996 Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way The dollar amounts increase automatically each year Yes No AFDC Need Standard in Effect As of July 16, 1996 Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement State: Texas Date Received: 3/31/14 Date Approved: 8/25/14 Date Effective: 1/1/14 Transmittal Number: TX 14-0002 MM1 Transmittal Number: TX 14-02 MM1 Date Approved: 8/25/14 Date Effective 1/1/14
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Page 6 of 7 Medicaid Eligibility Standard varies in some other way The dollar amounts increase automatically each year Yes No AFDC Payment Standard in Effect As of July 16, 1996, increased by no more than the percentage increase in the Consumer Price Index for urban consumers (CPI-U) since such date. Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way The dollar amounts increase automatically each year Yes No MAGI-equivalent AFDC Payment Standard in Effect As of July 16, 1996, increased by no more than the percentage increase in the Consumer Price Index for urban consumers (CPI-U) since such date Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way The dollar amounts increase automatically each year Yes No TANF payment standard Income Standard Entry - Dollar Amount - Automatic Increase Option S13a State: Texas Date Received: 3/31/14 Date Approved: 8/25/14 Date Effective: 1/1/14 Transmittal Number: TX 14-0002 MM1 Transmittal Number: TX 14-02 MM1 Date Approved: 8/25/14 Date Effective 1/1/14
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Page 7 of 7 Medicaid Eligibility The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way The dollar amounts increase automatically each year Yes No MAGI-equivalent TANF payment standard Income Standard Entry - Dollar Amount - Automatic Increase Option S13a The standard is as follows: Statewide standard Standard varies by region Standard varies by living arrangement Standard varies in some other way The dollar amounts increase automatically each year Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938‐1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4‐26‐05, Baltimore, Maryland 21244‐1850. State: Texas Date Received: 3/31/14 Date Approved: 8/25/14 Date Effective: 1/1/14 Transmittal Number: TX 14-0002 MM1 Transmittal Number: TX 14-02 MM1 Date Approved: 8/25/14 Date Effective 1/1/14
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Page 1 of 3 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Mandatory Coverage Parents and Other Caretaker Relatives S25 42 CFR 435.110 1902(a)(10)(A)(i)(I) 1931(b) and (d) Parents and Other Caretaker Relatives - Parents and other caretaker relatives of dependent children with household income at or below a standard established by the state. ■ The state attests that it operates this eligibility group in accordance with the following provisions: ✔ Individuals qualifying under this eligibility group must meet the following criteria: ■ Are parents or other caretaker relatives (defined at 42 CFR 435.4), including pregnant women, of dependent children (defined at 42 CFR 435.4) under age 18. Spouses of parents and other caretaker relatives are also included. ■ The state elects the following options: This eligibility group includes individuals who are parents or other caretakers of children who are 18 years old, provided the children are full-time students in a secondary school or the equivalent level of vocational or technical training. Options relating to the definition of caretaker relative (select any that apply): The definition of caretaker relative includes the domestic partner of the parent or other caretaker relative, even after the partnership is terminated. Definition of domestic partner: The definition of caretaker relative includes other relatives of the child based on blood (including those of half-blood), adoption or marriage. Description of other relatives: A person meets the relationship requirement if the person is by law, marriage, or adoption a child's father or mother; grandparent, to the degree of a "great, great, great" grandparent; brother or sister; uncle or aunt, to the degree of a "great, great" uncle or aunt; first cousin; nephew or niece, to the degree of a "great, great" nephew or niece; stepfather or stepmother; stepbrother or stepsister; or first cousin once removed. The definition of caretaker relative includes any adult with whom the child is living and who assumes primary responsibility for the dependent child's care. Options relating to the definition of dependent child (select the one that applies): The state elects to eliminate the requirement that a dependent child must be deprived of parental support or care by reason of the death, physical or mental incapacity, or absence from the home or unemployment of at least one parent. State: Texas Date Received: 3/31/14 Date Approved: 8/25/14 Date Effective: 1/1/14 Transmittal Number: TX 14-0002 MM1 Transmittal Number: TX 14-02 MM1 Date Approved: 8/25/14 Date Effective 1/1/14
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Page 2 of 3 Medicaid Eligibility The child must be deprived of parental support or care, but a less restrictive standard is used to measure unemployment of the parent (select the one that applies): Have household income at or below the standard established by the state. ■ MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state. ■ Income standard used for this group ■ Minimum income standard ■ The minimum income standard used for this group is the state's AFDC payment standard in effect as of May 1, 1988, converted to MAGI-equivalent amounts by household size. The standard is described in S14 AFDC Income Standards. The state certifies that it has submitted and received approval for its converted May 1, 1988 AFDC payment standard. ✔ An attachment is submitted. Maximum income standard ■ The state certifies that it has submitted and received approval for its converted income standard(s) for parents and other caretaker relatives to MAGI-equivalent standards and the determination of the maximum income standard to be used for parents and other caretaker relatives under this eligibility group. ✔ An attachment is submitted. The state's maximum income standard for this eligibility group is: The state's effective income level for section 1931 families under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for section 1931 families under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for any population of parents/caretaker relatives under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for any population of parents/caretaker relatives under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. Enter the amount of the maximum income standard: State: Texas Date Received: 3/31/14 Date Approved: 8/25/14 Date Effective: 1/1/14 Transmittal Number: TX 14-0002 MM1 Transmittal Number: TX 14-02 MM1 Date Approved: 8/25/14 Date Effective 1/1/14
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Page 3 of 3 Medicaid Eligibility A percentage of the federal poverty level: The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI-equivalent standard. The standard is described in S14 AFDC Income Standards. The state's AFDC payment standard in effect as of July 16, 1996, increased by no more than the percentage increase in the Consumer Price Index for urban consumers (CPI-U) since such date, converted to a MAGI- equivalent standard. The standard is described in S14 AFDC Income Standards. The state's TANF payment standard, converted to a MAGI-equivalent standard. The standard is described in S14 AFDC Income Standards. Other dollar amount % Income standard chosen: ■ Indicate the state's income standard used for this eligibility group: The minimum income standard The maximum income standard The state's AFDC payment standard in effect as of July 16, 1996, increased by no more than the percentage increase in the Consumer Price Index for urban consumers (CPI-U) since such date. The standard is described in S14 AFDC Income Standards. Another income standard in-between the minimum and maximum standards allowed There is no resource test for this eligibility group. ■ Presumptive Eligibility ■ The state covers individuals under this group when determined presumptively eligible by a qualified entity. The state assures it also covers individuals under the Pregnant Women (42 CFR 435.116) and/or Infants and Children under Age 19 (42 CFR 435.118) eligibility groups when determined presumptively eligible. Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. State: Texas Date Received: 3/31/14 Date Approved: 8/25/14 Date Effective: 1/1/14 Transmittal Number: TX 14-0002 MM1 Transmittal Number: TX 14-02 MM1 Date Approved: 8/25/14 Date Effective 1/1/14
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Page 1 of 4 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Mandatory Coverage Pregnant Women S28 42 CFR 435.116 1902(a)(10)(A)(i)(III) and (IV) 1902(a)(10)(A)(ii)(I), (IV) and (IX) 1931(b) and (d) 1920 Pregnant Women - Women who are pregnant or post-partum, with household income at or below a standard established by the state. ■ The state attests that it operates this eligibility group in accordance with the following provisions: ✔ Individuals qualifying under this eligibility group must be pregnant or post-partum, as defined in 42 CFR 435.4. ■ Pregnant women in the last trimester of their pregnancy without dependent children are eligible for full benefits under this group in accordance with section 1931 of the Act, if they meet the income standard for state plan Parents and Other Caretaker Relatives at 42 CFR 435.110. Yes No MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI-Based Income Methodologies, completed by the state. ■ Income standard used for this group ■ Minimum income standard (Once entered and approved by CMS, the minimum income standard cannot be changed.) ■ The state had an income standard higher than 133% FPL established as of December 19, 1989 for determining eligibility for pregnant women, or as of July 1, 1989, had authorizing legislation to do so. Yes No The minimum income standard for this eligibility group is 133% FPL. Maximum income standard ■ The state certifies that it has submitted and received approval for its converted income standard(s) for pregnant women to MAGI-equivalent standards and the determination of the maximum income standard to be used for pregnant women under this eligibility group. ✔ An attachment is submitted. The state's maximum income standard for this eligibility group is: The state's highest effective income level for coverage of pregnant women under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified pregnant women), 1902(a)(10)(A)(i)(IV) (mandatory poverty level- related pregnant women), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related pregnant women), 1902(a)(10) (A)(ii)(I) (pregnant women who meet AFDC financial eligibility criteria) and 1902(a)(10)(A)(ii)(IV) (institutionalized pregnant women) in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. Transmittal Number: TX 14-02 MM1 Date Approved: 8/25/14 Date Effective 1/1/14 State: Texas Date Received: 3/31/14 Date Approved: 8/25/14 Date Effective: 1/1/14 Transmittal Number: TX 14-0002 MM1
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Page 2 of 4 Medicaid Eligibility The state's highest effective income level for coverage of pregnant women under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified pregnant women), 1902(a)(10)(A)(i)(IV) (mandatory poverty level- related pregnant women), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related pregnant women), 1902(a)(10) (A)(ii)(I) (pregnant women who meet AFDC financial eligibility criteria) and 1902(a)(10)(A)(ii)(IV) (institutionalized pregnant women) in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of pregnant women under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of pregnant women under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. 185% FPL The amount of the maximum income standard is: 198 % FPL Income standard chosen ■ Indicate the state's income standard used for this eligibility group: The minimum income standard The maximum income standard Another income standard in-between the minimum and maximum standards allowed. There is no resource test for this eligibility group. ■ Benefits for individuals in this eligibility group consist of the following: ■ All pregnant women eligible under this group receive full Medicaid coverage under this state plan. Pregnant women whose income exceeds the income limit specified below for full coverage of pregnant women receive only pregnancy-related services. Presumptive Eligibility ■ The state covers ambulatory prenatal care for individuals under this group when determined presumptively eligible by a qualified entity. Yes No The presumptive period begins on the date the determination is made. ■ The end date of the presumptive period is the earlier of: ■ The date the eligibility determination for regular Medicaid is made, if an application for Medicaid is filed by the last day of the month following the month in which the determination of presumptive eligibility is made; or The last day of the month following the month in which the determination of presumptive eligibility is made, if no application for Medicaid is filed by that date. There may be no more than one period of presumptive eligibility per pregnancy. ■ A written application must be signed by the applicant or representative. Transmittal Number: TX 14-02 MM1 Date Approved: 8/25/14 Date Effective 1/1/14 State: Texas Date Received: 3/31/14 Date Approved: 8/25/14 Date Effective: 1/1/14 Transmittal Number: TX 14-0002 MM1
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Page 3 of 4 Medicaid Eligibility Yes No The state uses a single application form for Medicaid and presumptive eligibility, approved by CMS. The state uses a separate application form for presumptive eligibility, approved by CMS. A copy of the application form is included. An attachment is submitted. The presumptive eligibility determination is based on the following factors: ■ The woman must be pregnant ■ Household income must not exceed the applicable income standard at 42 CFR 435.116. ■ State residency Citizenship, status as a national, or satisfactory immigration status The state uses qualified entities, as defined in section 1920A of the Act, to determine eligibility presumptively for this eligibility group. ■ List of Qualified Entities S17 A qualified entity is an entity that is determined by the agency to be capable of making presumptive eligibility determinations based on an individual’s household income and other requirements, and that meets at least one of the following requirements. Select one or more of the following types of entities used to determine presumptive eligibility for this eligibility group: Furnishes health care items or services covered under the state's approved Medicaid state plan and is eligible to receive payments under the plan Is authorized to determine a child's eligibility to participate in a Head Start program under the Head Start Act Is authorized to determine a child's eligibility to receive child care services for which financial assistance is provided under the Child Care and Development Block Grant Act of 1990 Is authorized to determine a child's eligibility to receive assistance under the Special Supplemental Food Program for Women, Infants and Children (WIC) under section 17 of the Child Nutrition Act of 1966 Is authorized to determine a child's eligibility under the Medicaid state plan or for child health assistance under the Children's Health Insurance Program (CHIP) Is an elementary or secondary school, as defined in section 14101 of the Elementary and Secondary Education Act of 1965 (20 U.S.C. 8801) Is an elementary or secondary school operated or supported by the Bureau of Indian Affairs Is a state or Tribal child support enforcement agency under title IV-D of the Act Is an organization that provides emergency food and shelter under a grant under the Stewart B. McKinney Homeless Assistance Act Is a state or Tribal office or entity involved in enrollment in the program under Medicaid, CHIP, or title IV-A of the Act Transmittal Number: TX 14-02 MM1 Date Approved: 8/25/14 Date Effective 1/1/14 State: Texas Date Received: 3/31/14 Date Approved: 8/25/14 Date Effective: 1/1/14 Transmittal Number: TX 14-0002 MM1
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Page 4 of 4 Medicaid Eligibility Is an organization that determines eligibility for any assistance or benefits provided under any program of public or assisted housing that receives Federal funds, including the program under section 8 or any other section of the United States Housing Act of 1937 (42 U.S.C. 1437) or under the Native American Housing Assistance and Self Determination Act of 1996 (25 U.S.C. 4101 et seq.) Is a health facility operated by the Indian Health Service, a Tribe, or Tribal organization, or an Urban Indian Organization Other entity the agency determines is capable of making presumptive eligibility determinations: Name of entity Description + Family planning agency x The state assures that it has communicated the requirements for qualified entities, at 1920A(b)(3) of the Act, and has provided adequate training to the entities and organizations involved. A copy of the training materials has been included. ✔ An attachment is submitted. PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938‐1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4‐26‐05, Baltimore, Maryland 21244‐1850. Transmittal Number: TX 14-02 MM1 Date Approved: 8/25/14 Date Effective 1/1/14 State: Texas Date Received: 3/31/14 Date Approved: 8/25/14 Date Effective: 1/1/14 Transmittal Number: TX 14-0002 MM1
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Page 1 of 5 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Mandatory Coverage Infants and Children under Age 19 S30 42 CFR 435.118 1902(a)(10)(A)(i)(III), (IV), (VI) and (VII) 1902(a)(10)(A)(ii)(IV) and (IX) 1931(b) and (d) Infants and Children under Age 19 - Infants and children under age 19 with household income at or below standards established by the state based on age group. ■ The state attests that it operates this eligibility group in accordance with the following provisions: ✔ Children qualifying under this eligibility group must meet the following criteria: ■ Are under age 19 ■ Have household income at or below the standard established by the state. ■ MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state. ■ Income standard used for infants under age one ■ Minimum income standard ■ The state had an income standard higher than 133% FPL established as of December 19, 1989 for determining eligibility for infants under age one, or as of July 1, 1989, had authorizing legislation to do so. Yes No The minimum income standard for infants under age one is 133% FPL. Maximum income standard ■ The state certifies that it has submitted and received approval for its converted income standard(s) for infants under age one to MAGI-equivalent standards and the determination of the maximum income standard to be used for infants under age one. ✔ An attachment is submitted. The state's maximum income standard for this age group is: The state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(IV) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI- equivalent percent of FPL. State: Texas Date Received: 3/31/14 Date Approved: 8/25/14 Date Effective: 1/1/14 Transmittal Number: TX 14-0002 MM1 Transmittal Number: TX 14-02 MM1 Date Approved: 8/25/14 Date Effective 1/1/14
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Page 2 of 5 Medicaid Eligibility The state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(IV) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. 185% FPL Enter the amount of the maximum income standard: 198 % FPL Income standard chosen ■ The state's income standard used for infants under age one is: The maximum income standard If not chosen as the maximum income standard, the state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10) (A)(i)(IV) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of infants under age one under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10) (A)(i)(IV) (mandatory poverty level-related infants), 1902(a)(10)(A)(ii)(IX) (optional poverty level-related infants) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of infants under age one under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, 2010. Income standard for children age one through age five, inclusive ■ Minimum income standard ■ State: Texas Date Received: 3/31/14 Date Approved: 8/25/14 Date Effective: 1/1/14 Transmittal Number: TX 14-0002 MM1 Transmittal Number: TX 14-02 MM1 Date Approved: 8/25/14 Date Effective 1/1/14
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Page 3 of 5 Medicaid Eligibility The minimum income standard used for this age group is 133% FPL. Maximum income standard ■ The state certifies that it has submitted and received approval for its converted income standard(s) for children age one through five to MAGI-equivalent standards and the determination of the maximum income standard to be used for children age one through five. ✔ An attachment is submitted. The state's maximum income standard for children age one through five is: The state's highest effective income level for coverage of children age one through five under sections 1931 (low- income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level- related children age one through five), and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's highest effective income level for coverage of children age one through five under sections 1931 (low- income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level- related children age one through five), and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. Enter the amount of the maximum income standard: 144 % FPL Income standard chosen ■ The state's income standard used for children age one through five is: The maximum income standard If not chosen as the maximum income standard, the state's highest effective income level for coverage of children age one through five under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level-related children age one through five), and 1902(a)(10)(A)(ii) (IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of children age one through five under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VI) (mandatory poverty level-related children age one through five), and 1902(a)(10)(A)(ii) (IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. State: Texas Date Received: 3/31/14 Date Approved: 8/25/14 Date Effective: 1/1/14 Transmittal Number: TX 14-0002 MM1 Transmittal Number: TX 14-02 MM1 Date Approved: 8/25/14 Date Effective 1/1/14
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Page 4 of 5 Medicaid Eligibility If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age one through five under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL. Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, 2010. Income standard for children age six through age eighteen, inclusive ■ Minimum income standard ■ The minimum income standard used for this age group is 133% FPL. Maximum income standard ■ The state certifies that it has submitted and received approval for its converted income standard(s) for children age six through eighteen to MAGI-equivalent standards and the determination of the maximum income standard to be used for children age six through age eighteen. ✔ An attachment is submitted. The state's maximum income standard for children age six through eighteen is: The state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A)(ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. The state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. 133% FPL Income standard chosen ■ The state's income standard used for children age six through eighteen is: State: Texas Date Received: 3/31/14 Date Approved: 8/25/14 Date Effective: 1/1/14 Transmittal Number: TX 14-0002 MM1 Transmittal Number: TX 14-02 MM1 Date Approved: 8/25/14 Date Effective 1/1/14
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Page 5 of 5 Medicaid Eligibility The maximum income standard If not chosen as the maximum income standard, the state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A) (ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's highest effective income level for coverage of children age six through eighteen under sections 1931 (low-income families), 1902(a)(10)(A)(i)(III) (qualified children), 1902(a)(10)(A)(i)(VII) (mandatory poverty level-related children age six through eighteen) and 1902(a)(10)(A) (ii)(IV) (institutionalized children), in effect under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL. If higher than the highest effective income level for this age group under the state plan as of March 23, 2010, and if not chosen as the maximum income standard, the state's effective income level for any population of children age six through eighteen under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL. Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income standard for this age group in the state plan as of March 23, 2010. There is no resource test for this eligibility group. ■ Presumptive Eligibility ■ The state covers children when determined presumptively eligible by a qualified entity. Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938‐1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4‐26‐05, Baltimore, Maryland 21244‐1850. State: Texas Date Received: 3/31/14 Date Approved: 8/25/14 Date Effective: 1/1/14 Transmittal Number: TX 14-0002 MM1 Transmittal Number: TX 14-02 MM1 Date Approved: 8/25/14 Date Effective 1/1/14
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Page 1 of 1 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Mandatory Coverage Adult Group S32 1902(a)(10)(A)(i)(VIII) 42 CFR 435.119 The state covers the Adult Group as described at 42 CFR 435.119. Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938‐1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4‐26‐05, Baltimore, Maryland 21244‐1850. State: Texas Date Received: 3/31/14 Date Approved: 8/25/14 Date Effective: 1/1/14 Transmittal Number: TX 14-0002 MM1 Transmittal Number: TX 14-02 MM1 Date Approved: 8/25/14 Date Effective 1/1/14
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Page 1 of 1 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Mandatory Coverage Former Foster Care Children S33 42 CFR 435.150 1902(a)(10)(A)(i)(IX) Former Foster Care Children - Individuals under the age of 26, not otherwise mandatorily eligible, who were on Medicaid and in foster care when they turned age 18 or aged out of foster care. ■ The state attests that it operates this eligibility group under the following provisions: ✔ Individuals qualifying under this eligibility group must meet the following criteria: ■ Are under age 26. ■ Are not otherwise eligible for and enrolled for mandatory coverage under the state plan, except that eligibility under this group takes precedence over eligibility under the Adult Group. ■ Were in foster care under the responsibility of the state or Tribe and were enrolled in Medicaid under the state's state plan or 1115 demonstration when they turned 18 or at the time of aging out of that state's or Tribe's foster care program. ■ The state elects to cover children who were in foster care and on Medicaid in any state at the time they turned 18 or aged out of the foster care system. Yes No The state covers individuals under this group when determined presumptively eligible by a qualified entity. The state assures it also covers individuals under the Pregnant Women (42 CFR 435.116) and/or Infants and Children under Age 19 (42 CFR 435.118) eligibility groups when determined presumptively eligible. Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938‐1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4‐26‐05, Baltimore, Maryland 21244‐1850. State: Texas Date Received: 3/31/14 Date Approved: 8/25/14 Date Effective: 1/1/14 Transmittal Number: TX 14-0002 MM1 Transmittal Number: TX 14-02 MM1 Date Approved: 8/25/14 Date Effective 1/1/14
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Page 1 of 1 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Individuals above 133% FPL S50 1902(a)(10)(A)(ii)(XX) 1902(hh) 42 CFR 435.218 Individuals above 133% FPL - The state elects to cover individuals under 65, not otherwise mandatorily or optionally eligible, with income above 133% FPL and at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.218. Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. State: Texas Date Received: 3/31/14 Date Approved: 8/25/14 Date Effective: 1/1/14 Transmittal Number: TX 14-0002 MM1 Transmittal Number: TX 14-02 MM1 Date Approved: 8/25/14 Date Effective 1/1/14
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Page 1 of 1 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Optional Coverage of Parents and Other Caretaker Relatives S51 42 CFR 435.220 1902(a)(10)(A)(ii)(I) Optional Coverage of Parents and Other Caretaker Relatives - The state elects to cover individuals qualifying as parents or other caretaker relatives who are not mandatorily eligible and who have income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.220. Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. State: Texas Date Received: 3/31/14 Date Approved: 8/25/14 Date Effective: 1/1/14 Transmittal Number: TX 14-0002 MM1 Transmittal Number: TX 14-02 MM1 Date Approved: 8/25/14 Date Effective 1/1/14
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Page 1 of 11 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Reasonable Classification of Individuals under Age 21 S52 42 CFR 435.222 1902(a)(10)(A)(ii)(I) 1902(a)(10)(A)(ii)(IV) Reasonable Classification of Individuals under Age 21 - The state elects to cover one or more reasonable classifications of individuals under age 21 who are not mandatorily eligible and who have income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.222. Yes No The state attests that it operates this eligibility group in accordance with the following provisions: ✔ Individuals qualifying under this eligibility group must qualify under a reasonable classification by meeting the following criteria: ■ Be under age 21, or a lower age, as defined within the reasonable classification. ■ Have household income at or below the standard established by the state, if the state has an income standard for the reasonable classification. ■ Not be eligible and enrolled for mandatory coverage under the state plan. ■ MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state. ■ The state covered at least one reasonable classification under this eligibility group under its Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013, with income standards higher (including disregarding all income) than the current mandatory income standards for the individual's age. Yes No The state also covered at least one reasonable classification under this group in the Medicaid state plan as of March 23, 2010 with income standards higher (including disregarding all income) than the current mandatory income standards for the individual's age. Yes No Reasonable Classifications Covered in the Medicaid State Plan as of March 23, 2010 The state attaches the approved pages from the Medicaid state plan as of March 23, 2010 to indicate the age groups, reasonable classifications, and income standards used at that time for this eligibility group. An attachment is submitted. Current Coverage of All Children under a Specified Age State: Texas Date Received: 3/31/14 Date Approved: 8/25/14 Date Effective: 1/1/14 Transmittal Number: TX 14-0002 MM1 Transmittal Number: TX 14-02 MM1 Date Approved: 8/25/14 Date Effective 1/1/14
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Page 2 of 11 Medicaid Eligibility The state covers all children under a specified age limit, equal to or higher than the age limit and/or income standard used in the Medicaid state plan as of March 23, 2010, provided the income standard is higher than the current mandatory income standard for the individual's age. The age limit and/or income standard used must be no higher than any age limit and/or income standard covered in the Medicaid state plan as of December 31, 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Higher income standards may include the disregard of all income. Yes No Current Coverage of Reasonable Classifications Covered in the Medicaid State Plan as of March 23, 2010 The state covers reasonable classifications of children previously covered in the Medicaid state plan as of March 23, 2010, with income standards higher than the current mandatory income standard for the age group. Age limits and income standards are equal to or higher than the Medicaid state plan as of March 23, 2010, but no higher than any age limit and/or income standard for this classification covered in the Medicaid state plan as of December 31, 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Higher income standards may include the disregard of all income. Yes No Indicate the reasonable classifications of children that were covered in the state plan in effect as of March 23, 2010 with income standards higher than the mandatory standards used for the child's age, using age limits and income standards that are not more restrictive than used in the state plan as of as March 23, 2010 and are not less restrictive than used in the Medicaid state plan as of December 31, 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Current Coverage of Reasonable Classifications Covered in the Medicaid State Plan as of March 23, 2010 Reasonable Classifications of Children S11 Individuals for whom public agencies are assuming full or partial financial responsibility. Individuals placed in foster care homes by public agencies Indicate the age which applies: Under age 21 Under age 20 Under age 19 Under age 18 Individuals placed in foster care homes by private, non-profit agencies Indicate the age which applies: Under age 21 Under age 20 Under age 19 Under age 18 Individuals placed in private institutions by public agencies Indicate the age which applies: Under age 21 Under age 20 Under age 19 Under age 18 Individuals placed in private institutions by private, non-profit agencies Indicate the age which applies: Under age 21 Under age 20 Under age 19 Under age 18 Individuals in adoptions subsidized in full or part by a public agency State: Texas Date Received: 3/31/14 Date Approved: 8/25/14 Date Effective: 1/1/14 Transmittal Number: TX 14-0002 MM1 Transmittal Number: TX 14-02 MM1 Date Approved: 8/25/14 Date Effective 1/1/14
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Page 3 of 11 Medicaid Eligibility Individuals in nursing facilities, if nursing facility services are provided under this plan Individuals receiving active treatment as inpatients in psychiatric facilities or programs, if such services are provided under this plan Other reasonable classifications Name of classification Description Age Limit + AFDC Children in the community who are under the age of 18 (or under age 19 if expected to graduate by their 19th birthday and who live with relative(s)) within the Aid for Families with Dependent Children (AFDC) required degree of relationship. Under age 19 x + TJJD Children under the age of 21 who have been committed to the custody of the Texas Juvenile Justice Department. Under age 21 x + Jurisdiction of juvenile court Children ages 10 through 17 who are under the continuing jurisdiction of the juvenile court and who are placed in a setting such as a group home, a residential treatment facility, or a foster home which will permit children to receive Medicaid services. Under age 18 x Enter the income standard used for these classifications. The income standard must be higher than the mandatory standard for the child's age. It may be no lower than the income standard used in the state plan as of March 23, 2010 and no higher than the highest standard used in the Medicaid state plan as of December 31, 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Click here once S11 form above is complete to view the income standards form. Individuals placed in foster care homes by public agencies Income standard used ■ Minimum income standard ■ The minimum income standard for this classification of children is the AFDC payment standard in effect as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in S14 AFDC Income Standards. Maximum income standard ■ No income test was used (all income was disregarded) for this classification either in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No State: Texas Date Received: 3/31/14 Date Approved: 8/25/14 Date Effective: 1/1/14 Transmittal Number: TX 14-0002 MM1 Transmittal Number: TX 14-02 MM1 Date Approved: 8/25/14 Date Effective 1/1/14
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Page 4 of 11 Medicaid Eligibility No income test was used (all income was disregarded) for this classification under: ■ (check all that apply) The Medicaid state plan as of March 23, 2010. The Medicaid state plan as of December 31, 2013. A Medicaid 1115 Demonstration as of March 23, 2010. A Medicaid 1115 Demonstration as of December 31, 2013. The state's maximum standard for this classification of children is no income test (all income is disregarded). Income standard chosen ■ Individuals qualify under this classification under the following income standard: This classification does not use an income test (all income is disregarded). The minimum standard. Another income standard higher than both the minimum income standard and the effective income level for this classification in the state plan as of March 23, 2010, converted to a MAGI equivalent. Individuals placed in foster care homes by private, non-profit agencies Income standard used ■ Minimum income standard ■ The minimum income standard for this classification of children is the AFDC payment standard in effect as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in S14 AFDC Income Standards. Maximum income standard ■ No income test was used (all income was disregarded) for this classification either in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No No income test was used (all income was disregarded) for this classification under: ■ (check all that apply) The Medicaid state plan as of March 23, 2010. The Medicaid state plan as of December 31, 2013. A Medicaid 1115 Demonstration as of March 23, 2010. A Medicaid 1115 Demonstration as of December 31, 2013. State: Texas Date Received: 3/31/14 Date Approved: 8/25/14 Date Effective: 1/1/14 Transmittal Number: TX 14-0002 MM1 Transmittal Number: TX 14-02 MM1 Date Approved: 8/25/14 Date Effective 1/1/14
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Page 5 of 11 Medicaid Eligibility The state's maximum standard for this classification of children is no income test (all income is disregarded). Income standard chosen ■ Individuals qualify under this classification under the following income standard: This classification does not use an income test (all income is disregarded). The minimum standard. Another income standard higher than both the minimum income standard and the effective income level for this classification in the state plan as of March 23, 2010, converted to a MAGI equivalent. Individuals placed in private institutions by public agencies Income standard used ■ Minimum income standard ■ The minimum income standard for this classification of children is the AFDC payment standard in effect as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in S14 AFDC Income Standards. Maximum income standard ■ No income test was used (all income was disregarded) for this classification either in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No No income test was used (all income was disregarded) for this classification under: ■ (check all that apply) The Medicaid state plan as of March 23, 2010. The Medicaid state plan as of December 31, 2013. A Medicaid 1115 Demonstration as of March 23, 2010. A Medicaid 1115 Demonstration as of December 31, 2013. The state's maximum standard for this classification of children is no income test (all income is disregarded). Income standard chosen ■ Individuals qualify under this classification under the following income standard: This classification does not use an income test (all income is disregarded). The minimum standard. State: Texas Date Received: 3/31/14 Date Approved: 8/25/14 Date Effective: 1/1/14 Transmittal Number: TX 14-0002 MM1 Transmittal Number: TX 14-02 MM1 Date Approved: 8/25/14 Date Effective 1/1/14
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Page 6 of 11 Medicaid Eligibility Another income standard higher than both the minimum income standard and the effective income level for this classification in the state plan as of March 23, 2010, converted to a MAGI equivalent. Individuals placed in private institutions by private, non-profit agencies Income standard used ■ Minimum income standard ■ The minimum income standard for this classification of children is the AFDC payment standard in effect as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in S14 AFDC Income Standards. Maximum income standard ■ No income test was used (all income was disregarded) for this classification either in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No No income test was used (all income was disregarded) for this classification under: ■ (check all that apply) The Medicaid state plan as of March 23, 2010. The Medicaid state plan as of December 31, 2013. A Medicaid 1115 Demonstration as of March 23, 2010. A Medicaid 1115 Demonstration as of December 31, 2013. The state's maximum standard for this classification of children is no income test (all income is disregarded). Income standard chosen ■ Individuals qualify under this classification under the following income standard: This classification does not use an income test (all income is disregarded). The minimum standard. Another income standard higher than both the minimum income standard and the effective income level for this classification in the state plan as of March 23, 2010, converted to a MAGI equivalent. AFDC Income standard used ■ Minimum income standard ■ State: Texas Date Received: 3/31/14 Date Approved: 8/25/14 Date Effective: 1/1/14 Transmittal Number: TX 14-0002 MM1 Transmittal Number: TX 14-02 MM1 Date Approved: 8/25/14 Date Effective 1/1/14
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Page 7 of 11 Medicaid Eligibility The minimum income standard for this classification of children must exceed the lowest income standard chosen for children under this age under the Infants and Children under Age 19 eligibility group. Maximum income standard ■ No income test was used (all income was disregarded) for this classification either in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No No income test was used (all income was disregarded) for this classification under: ■ (check all that apply) The Medicaid state plan as of March 23, 2010. The Medicaid state plan as of December 31, 2013. A Medicaid 1115 Demonstration as of March 23, 2010. A Medicaid 1115 Demonstration as of December 31, 2013. The state's maximum standard for this classification of children is no income test (all income is disregarded). Income standard chosen ■ Individuals qualify under this classification under the following income standard: This classification does not use an income test (all income is disregarded). Another income standard higher than both the minimum income standard and the effective income level for this classification in the state plan as of March 23, 2010, converted to a MAGI equivalent. TJJD Income standard used ■ Minimum income standard ■ The minimum income standard for this classification of children is the AFDC payment standard in effect as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in S14 AFDC Income Standards. Maximum income standard ■ No income test was used (all income was disregarded) for this classification either in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No No income test was used (all income was disregarded) for this classification under: ■ State: Texas Date Received: 3/31/14 Date Approved: 8/25/14 Date Effective: 1/1/14 Transmittal Number: TX 14-0002 MM1 Transmittal Number: TX 14-02 MM1 Date Approved: 8/25/14 Date Effective 1/1/14
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Page 8 of 11 Medicaid Eligibility (check all that apply) The Medicaid state plan as of March 23, 2010. The Medicaid state plan as of December 31, 2013. A Medicaid 1115 Demonstration as of March 23, 2010. A Medicaid 1115 Demonstration as of December 31, 2013. The state's maximum standard for this classification of children is no income test (all income is disregarded). Income standard chosen ■ Individuals qualify under this classification under the following income standard: This classification does not use an income test (all income is disregarded). The minimum standard. Another income standard higher than both the minimum income standard and the effective income level for this classification in the state plan as of March 23, 2010, converted to a MAGI equivalent. Jurisdiction of juvenile court Income standard used ■ Minimum income standard ■ The minimum income standard for this classification of children must exceed the lowest income standard chosen for children under this age under the Infants and Children under Age 19 eligibility group. Maximum income standard ■ No income test was used (all income was disregarded) for this classification either in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No No income test was used (all income was disregarded) for this classification under: ■ (check all that apply) The Medicaid state plan as of March 23, 2010. The Medicaid state plan as of December 31, 2013. A Medicaid 1115 Demonstration as of March 23, 2010. A Medicaid 1115 Demonstration as of December 31, 2013. The state's maximum standard for this classification of children is no income test (all income is disregarded). State: Texas Date Received: 3/31/14 Date Approved: 8/25/14 Date Effective: 1/1/14 Transmittal Number: TX 14-0002 MM1 Transmittal Number: TX 14-02 MM1 Date Approved: 8/25/14 Date Effective 1/1/14
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Page 9 of 11 Medicaid Eligibility Income standard chosen ■ Individuals qualify under this classification under the following income standard: This classification does not use an income test (all income is disregarded). Another income standard higher than both the minimum income standard and the effective income level for this classification in the state plan as of March 23, 2010, converted to a MAGI equivalent. Other Reasonable Classifications Previously Covered The state covers reasonable classifications of children not covered in the Medicaid state plan as of March 23, 2010, but covered under the Medicaid state plan as of December 31, 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013 with an income standard higher than the current mandatory income standard for the age group. Yes No The additional previously covered reasonable classifications to be included are: Additional Previously Covered Reasonable Classifications Included Reasonable Classifications of Children S11 Individuals for whom public agencies are assuming full or partial financial responsibility. Individuals in adoptions subsidized in full or part by a public agency Individuals in nursing facilities, if nursing facility services are provided under this plan Individuals receiving active treatment as inpatients in psychiatric facilities or programs, if such services are provided under this plan Other reasonable classifications Name of classification Description Age Limit + ICPC Former foster care youth under the age of 21 who had been placed inside or outside of Texas under the Interstate Compact on the Placement of Children in accordance with Texas Family Code 162.102. Under age 21 x Enter the income standard used for these classifications (which must be higher than the mandatory standard for the child's age but may be no higher than the highest standard used in the state plan as of December 31, 2013 or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013). Click here once S11 form above is complete to view the income standards form. ICPC State: Texas Date Received: 3/31/14 Date Approved: 8/25/14 Date Effective: 1/1/14 Transmittal Number: TX 14-0002 MM1 Transmittal Number: TX 14-02 MM1 Date Approved: 8/25/14 Date Effective 1/1/14
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Page 10 of 11 Medicaid Eligibility Income standard used ■ Minimum income standard ■ The minimum income standard for this classification of children is the AFDC payment standard in effect as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in S14 AFDC Income Standards. Maximum income standard ■ No income test was used (all income was disregarded) for this classification either in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No No income test was used (all income was disregarded) for this classification under: ■ (check all that apply) The Medicaid state plan as of March 23, 2010. The Medicaid state plan as of December 31, 2013. A Medicaid 1115 Demonstration as of March 23, 2010. A Medicaid 1115 Demonstration as of December 31, 2013. The state's maximum standard for this classification of children is no income test (all income is disregarded). Income standard chosen ■ Individuals qualify under this classification under the following income standard: This classification does not use an income test (all income is disregarded). The minimum standard. Another income standard higher than both the minimum income standard and the effective income level for this classification in the state plan as of March 23, 2010, converted to a MAGI equivalent. Additional new age groups or reasonable classifications covered If the state has not elected to cover the Adult Group (42 CFR 435.119), it may elect to cover additional new age groups or reasonable classifications that have not been covered previously. If the state covers the Adult Group, this additional option is not available, as the standard for the new age groups or classifications is lower than that used for mandatory coverage. The state does not cover the Adult Group and elects the option to include in this eligibility group additional age groups or reasonable classifications that have not been covered previously in the state plan or under a Medicaid 1115 Demonstration. Any additional age groups or reasonable classifications not previously covered are restricted to the AFDC income standard from July 16, 1996, not converted to a MAGI-equivalent standard. Yes No State: Texas Date Received: 3/31/14 Date Approved: 8/25/14 Date Effective: 1/1/14 Transmittal Number: TX 14-0002 MM1 Transmittal Number: TX 14-02 MM1 Date Approved: 8/25/14 Date Effective 1/1/14
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Page 11 of 11 Medicaid Eligibility There is no resource test for this eligibility group. ■ PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. State: Texas Date Received: 3/31/14 Date Approved: 8/25/14 Date Effective: 1/1/14 Transmittal Number: TX 14-0002 MM1 Transmittal Number: TX 14-02 MM1 Date Approved: 8/25/14 Date Effective 1/1/14
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Page 1 of 2 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Children with Non IV-E Adoption Assistance S53 42 CFR 435.227 1902(a)(10)(A)(ii)(VIII) Children with Non IV-E Adoption Assistance - The state elects to cover children with special needs for whom there is a non IV-E adoption assistance agreement in effect with a state, who were eligible for Medicaid, or who had income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.227. Yes No The state attests that it operates this eligibility group in accordance with the following provisions: ✔ Individuals qualifying under this eligibility group must meet the following criteria: ■ The state adoption agency has determined that they cannot be placed without Medicaid coverage because of special needs for medical or rehabilitative care; ■ Are under the following age (see the Guidance for restrictions on the selection of an age): ■ Under age 21 Under age 20 Under age 19 Under age 18 MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state. ■ The state covered this eligibility group in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No The state also covered this eligibility group in the Medicaid state plan as of March 23, 2010. Yes No Individuals qualify under this eligibility group if they were eligible under the state's approved state plan prior to the execution of the adoption agreement. ■ The state used an income standard or disregarded all income for this eligibility group either in the Medicaid state plan as of March 23, 2010 or December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No Income standard used for this eligibility group ■ Minimum income standard ■ The minimum income standard for this eligibility group is the AFDC payment standard in effect as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in S14 AFDC Income Standards. Maximum income standard ■ State: Texas Date Received: 3/31/14 Date Approved: 8/25/14 Date Effective: 1/1/14 Transmittal Number: TX 14-0002 MM1 Transmittal Number: TX 14-02 MM1 Date Approved: 8/25/14 Date Effective 1/1/14
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Page 2 of 2 Medicaid Eligibility No income test was used (all income was disregarded) for this eligibility group either in the Medicaid state plan as of March 23, 2010 or December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No No income test was used (all income was disregarded) for this eligibility group under (check all that apply): ■ The Medicaid state plan as of March 23, 2010. The Medicaid state plan as of December 31, 2013. A Medicaid 1115 Demonstration as of March 23, 2010. A Medicaid 1115 Demonstration as of December 31, 2013. The state's maximum standard for this eligibility group is no income test (all income is disregarded). Income standard chosen ■ Individuals qualify under this eligibility group under the following income standard, which must be higher than the minimum for this child's age: The minimum standard. This eligibility group does not use an income test (all income is disregarded). Another income standard higher than both the minimum income standard and the effective income level for this eligibility group in the state plan as of March 23, 2010, converted to a MAGI-equivalent. There is no resource test for this eligibility group. ■ PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. State: Texas Date Received: 3/31/14 Date Approved: 8/25/14 Date Effective: 1/1/14 Transmittal Number: TX 14-0002 MM1 Transmittal Number: TX 14-02 MM1 Date Approved: 8/25/14 Date Effective 1/1/14
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Page 1 of 1 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Optional Targeted Low Income Children S54 1902(a)(10)(A)(ii)(XIV) 42 CFR 435.229 and 435.4 1905(u)(2)(B) Optional Targeted Low Income Children - The state elects to cover uninsured children who meet the definition of optional targeted low income children at 42 CFR 435.4, who have household income at or below a standard established by the state and in accordance with provisions described at 42 CFR 435.229. Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. State: Texas Date Received: 3/31/14 Date Approved: 8/25/14 Date Effective: 1/1/14 Transmittal Number: TX 14-0002 MM1 Transmittal Number: TX 14-02 MM1 Date Approved: 8/25/14 Date Effective 1/1/14
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Page 1 of 1 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Individuals with Tuberculosis S55 1902(a)(10)(A)(ii)(XII) 1902(z) Individuals with Tuberculosis - The state elects to cover individuals infected with tuberculosis who have income at or below a standard established by the state, limited to tuberculosis-related services. Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. State: Texas Date Received: 3/31/14 Date Approved: 8/25/14 Date Effective: 1/1/14 Transmittal Number: TX 14-0002 MM1 Transmittal Number: TX 14-02 MM1 Date Approved: 8/25/14 Date Effective 1/1/14
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Page 1 of 3 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Independent Foster Care Adolescents S57 42 CFR 435.226 1902(a)(10)(A)(ii)(XVII) Independent Foster Care Adolescents - The state elects to cover individuals under an age specified by the state, less than age 21, who were in state-sponsored foster care on their 18th birthday and who meet the income standard established by the state and in accordance with the provisions described at 42 CFR 435.226. Yes No The state attests that it operates this eligibility group in accordance with the following provisions: ✔ Individuals qualifying under this eligibility group must meet the following criteria: ■ Are under the following age ■ Under age 21 Under age 20 Under age 19 Were in foster care under the responsibility of a state on their 18th birthday. ■ Are not eligible and enrolled for mandatory coverage under the Medicaid state plan. ■ Have household income at or below a standard established by the state. ■ MAGI-based income methodologies are used in calculating household income. Please refer as necessary to S10 MAGI- Based Income Methodologies, completed by the state. ■ The state covered this eligibility group under its Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 demonstration as of March 23, 2010 or December 31, 2013. Yes No The state also covered this eligibility group in the Medicaid state plan as of March 23, 2010. Yes No The state covers children under this eligibility group, as follows (selection may not be more restrictive than the coverage in the Medicaid state plan as of March 23, 2010 until October 1, 2019, nor more liberal than the most liberal coverage in the Medicaid state plan as of December 31, 2013, or under a Medicaid 1115 demonstration as of March 23, 2010 or December 31, 2013): ■ All children under the age selected A reasonable classification of children under the age selected: Individuals for whom foster care maintenance payments or independent living services were furnished under a program funded under title IV-E before the date the individual turned 18 years old. Other reasonable classification Description : Individuals who were in foster care when they left the Texas Department of Family and Protective Services conservatorship on their 18th birthday or later, until they reach age 21. State: Texas Date Received: 3/31/14 Date Approved: 8/25/14 Date Effective: 1/1/14 Transmittal Number: TX 14-0002 MM1 Transmittal Number: TX 14-02 MM1 Date Approved: 8/25/14 Date Effective 1/1/14
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Page 2 of 3 Medicaid Eligibility Income standard used for this eligibility group ■ Minimum income standard ■ The minimum income standard for this classification of children is the AFDC payment standard in effect as of July 16, 1996, not converted to MAGI-equivalent. This standard is described in S14 AFDC Income Standards. Maximum income standard ■ No income test was used (all income was disregarded) for this eligibility group either in the Medicaid state plan as of March 23, 2010 or December 31, 2013, or under a Medicaid 1115 Demonstration as of March 23, 2010 or December 31, 2013. Yes No The state certifies that it has submitted and received approval for its converted income standard(s) for Independent Foster Care Adolescents to MAGI-equivalent standards and the determination of the maximum income standard to be used for individuals under this eligibility group. ✔ An attachment is submitted. The state's maximum income standard for this eligibility group (which must exceed the minimum) is: The state's effective income level for independent foster care adolescents under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for independent foster care adolescents under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for independent foster care adolescents under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. The state's effective income level for independent foster care adolescents under the Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. Enter the amount of the maximum income standard: A percentage of the federal poverty level: The state's AFDC payment standard in effect as of July 16, 1996, converted to a MAGI-equivalent standard. This standard is described in S14 AFDC Income Standards. This option should be selected only if Under age 21 or Under age 20 was selected, and if the state has not elected to cover the Adult Group. The state's TANF payment standard, converted to a MAGI-equivalent standard. This standard is described in S14 AFDC Income Standards. This option should be selected only if Under age 21 or Under age 20 was selected, and if the state has not elected to cover the Adult Group. Other dollar amount % 413 Income standard chosen ■ Individuals qualify under this eligibility group under the following income standard: State: Texas Date Received: 3/31/14 Date Approved: 8/25/14 Date Effective: 1/1/14 Transmittal Number: TX 14-0002 MM1 Transmittal Number: TX 14-02 MM1 Date Approved: 8/25/14 Date Effective 1/1/14
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Page 3 of 3 Medicaid Eligibility The minimum standard. The maximum income standard. If not chosen as the maximum income standard, the state's effective income level for independent foster care adolescents under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for independent foster care adolescents under a Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL, or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for independent foster care adolescents under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. If not chosen as the maximum income standard, and if higher than the effective income level used under the Medicaid state plan as of March 23, 2010, the state's effective income level for independent foster care adolescents under the Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size. Another income standard in-between the minimum and maximum standards allowed, provided it is higher than the effective income level for independent foster care adolescents in the Medicaid state plan as of March 23, 2010, converted to a MAGI equivalent. There is no resource test for this eligibility group. ■ PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. State: Texas Date Received: 3/31/14 Date Approved: 8/25/14 Date Effective: 1/1/14 Transmittal Number: TX 14-0002 MM1 Transmittal Number: TX 14-02 MM1 Date Approved: 8/25/14 Date Effective 1/1/14
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Page 1 of 1 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 Eligibility Groups - Options for Coverage Individuals Eligible for Family Planning Services S59 1902(a)(10)(A)(ii)(XXI) 42 CFR 435.214 Individuals Eligible for Family Planning Services - The state elects to cover individuals who are not pregnant, and have household income at or below a standard established by the state, whose coverage is limited to family planning and related services and in accordance with provisions described at 42 CFR 435.214. Yes No PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. State: Texas Date Received: 3/31/14 Date Approved: 8/25/14 Date Effective: 1/1/14 Transmittal Number: TX 14-0002 MM1 Transmittal Number: TX 14-02 MM1 Date Approved: 8/25/14 Date Effective 1/1/14
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FORM HCFA-179 (07-92)
MEDICAID ADMINISTRATION
TRANSMITTAL NUMBER:
14-0002 MM1 STATE:
Texas
The agency continues to apply the waiver of provisions of Part A of Title IV in effect as of July 16, 1996, submitted prior to August 22, 1996, and approved by the Secretary on or before July 1, 1997, which allows removal of the 100- hour rule for meeting the Medicaid deprivation eligibility criteria for two-parent families. Unemployment is defined as an individual working 0 hours. Underemployment is defined as an individual working, but not earning enough to make the household ineligible for Parents and Caretaker Relatives Medicaid.
State: Texas Date Received: 3/31/14 Date Approved: 8/25/14 Date Effective: 1/1/14 Transmittal Number: TX 14-0002 MM1 Transmittal Number: TX 14-02 MM1 Date Approved: 8/25/14 Date Effective 1/1/14
(spa)(tx-14-0003-mm3)(approval-document)Texas Medicaid SPA TX-14-0003-MM3: Approval Document (approved September 24, 2014, effective January 1, 2014)#
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_____________________________________________________________________________
Table of Contents State/Territory Name: Texas State Plan Amendment (SPA) #: 14-0003 MM3 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Superseding Page Listing 4) Approved SPA Pages
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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Dallas Regional Office 1301 Young Street, Suite 833 Dallas, Texas 75202
DIVISION OF MEDICAID & CHILDREN’S HEALTH - REGION VI
September 24, 2014 Our Reference: SPA TX 14-0003 MM3 Ms. Kay Ghahremani State Medicaid/CHIP Director Health and Human Services Commission Post Office Box 13247 Mail Code H100 Austin, Texas 78711 Dear Ms. Ghahremani: We have reviewed the State’s proposed amendment to the Texas State Plan submitted under Transmittal Number 14-0003 MM3, dated March 1, 2014. This state plan amendment establishes that the Texas Health and Human Services Commission (HHSC) will determine financial eligibility for most Medicaid programs using the new federal income rules. Federal law requires states to base household income and composition on federal income tax rules that use modified gross income (MAGI) methodologies. The state selected the option on the S10 plan page to include available cash support as household income, exceeding nominal amounts, provided by the person claiming an individual described at 42 CFR § 435.603 (f) (2) (i) as a tax dependent. The state originally proposed a nominal amount of $0. CMS recommended changing this amount since a nominal amount of $0 per month would not be approved. Based on discussions with the state, the state has agreed to implement a nominal amount of $50 per month beginning April 2015. Based on the information submitted, we have approved the amendment for incorporation into the official Texas State Plan with an effective date change of January 1, 2014. A copy of the CMS- 179 and approved plan pages are enclosed with this letter. If you have questions, please contact Cheryl Rupley at (214) 767-6278. Sincerely, Bill Brooks Associate Regional Administrator cc: Becky Brownlee, Policy Development Support
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TX.0790.ROO.OO - Jan 01, 2014 Medicaid State Plan Eligibility: Summary Page (CMS 179) Statefferritory name: Texas Transmittal Number: Page 1 of 1 Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY =the last two digits of the submission year, and 0000 =a four digit number with leading zeros. The dashes must also be entered. TX-14-0003 Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 1902(e)(l4); 42 CFR 435.603 Federal Budget Impact Federal Fiscal Year First Year 2014 Second Year 2015 Subject of Amendment $0.00 $0.00 Amount The purpose of this amendment is to provide that HHSC will determine financial eligibility for most Medicaid programs using new federal income rules. Federal law requires states to base household income and composition on federal income tax rules that use modified adjusted gross income (MAGI) methodologies. The proposed amendment is effective January I, 2014. Governor's Office Review Governor's office reported no comment Comments of Governor's office received Describe: No reply received within 45 days of submittal Other, as specified Describe: Sent to Govemorii€™s Office this date. Comments, if any, will be forwarded upon receipt. Signature of State Agency Official Submitted By: Siani Kayani Last Revision Date: Date Received: Sep 24• 2014 Date Approved: Submit Date: 3/1/14 9/24/14 Mar 1, 2014 Signature of Approval Official Printed Name and Title: Bill Brooks Associated Regional Administrator Div of Medicaid & Children's Health -
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SUPERSEDING PAGES OF STATE PLAN MATERIAL
TRANSMITTAL NUMBER:
TX-14-0003-MM3 STATE:
Texas
PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:
S10 - MAGI Income Methodology
PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable):
Notwithstanding any other provisions of the Texas Medicaid State Plan, the financial eligibility methodologies described in State Plan Amendment TX-14-0003-MM3 will apply to all MAGI- based eligibility groups covered under Texas’ Medicaid State Plan. The MAGI financial methodologies set forth in 42 CFR § 435.603 apply to everyone except those individuals described at 42 CFR § 435.603(j) for whom MAGI-based methods do not apply. This State Plan Amendment supersedes the current financial eligibility provisions of the Medicaid State Plan only with respect to the MAGI-based eligibility groups.
TN: TX 14-03 MM3
Date Approved: 9-24-14 Date Effective: 1/1/14 State: Texas Date Received: 3/1/14 Date Approved: 9/24/14 Date Effective: 1/1/14 Transmittal Number: 14-003 MM3
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Page 1 of 2 Medicaid Eligibility OMB Control Number 0938-1148 OMB Expiration date: 10/31/2014 MAGI-Based Income Methodologies S10 1902(e)(14) 42 CFR 435.603 The state will apply Modified Adjusted Gross Income (MAGI)-based methodologies as described below, and consistent with 42 CFR 435.603. ■ In the case of determining ongoing eligibility for beneficiaries determined eligible for Medicaid on or before December 31, 2013, MAGI-based income methodologies will not be applied until March 31, 2014, or the next regularly-scheduled renewal of eligibility, whichever is later, if application of such methods results in a determination of ineligibility prior to such date. In determining family size for the eligibility determination of a pregnant woman, she is counted as herself plus each of the children she is expected to deliver. In determining family size for the eligibility determination of the other individuals in a household that includes a pregnant woman: The pregnant woman is counted just as herself. The pregnant woman is counted as herself, plus one. The pregnant woman is counted as herself, plus the number of children she is expected to deliver. Financial eligibility is determined consistent with the following provisions: When determining eligibility for new applicants, financial eligibility is based on current monthly income and family size. When determining eligibility for current beneficiaries, financial eligibility is based on: Current monthly household income and family size Projected annual household income and family size for the remaining months of the current calendar year In determining current monthly or projected annual household income, the state will use reasonable methods to: Include a prorated portion of a reasonably predictable increase in future income and/or family size. Account for a reasonably predictable decrease in future income and/or family size. Except as provided at 42 CFR 435.603(d)(2) through (d)(4), household income is the sum of the MAGI-based income of every individual included in the individual's household. In determining eligibility for Medicaid, an amount equivalent to 5 percentage points of the FPL for the applicable family size will be deducted from household income in accordance with 42 CFR 435.603(d). Household income includes actually available cash support, exceeding nominal amounts, provided by the person claiming an individual described at §435.603(f)(2)(i) as a tax dependent. Yes No TN: TX 14-03 MM3
Date Approved: 9-24-14 Date Effective: 1/1/14 State: Texas Date Received: 3/1/14 Date Approved: 9/24/14 Date Effective: 1/1/14 Transmittal Number: 14-003 MM3
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Page 2 of 2 Medicaid Eligibility The age used for children with respect to 42 CFR 435.603(f)(3)(iv) is: ■ Age 19 Age 19, or in the case of full-time students, age 21 PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. TN: TX 14-03 MM3
Date Approved: 9-24-14 Date Effective: 1/1/14 State: Texas Date Received: 3/1/14 Date Approved: 9/24/14 Date Effective: 1/1/14 Transmittal Number: 14-003 MM3
(spa)(tx-15-0004)(approval-document)Texas Medicaid SPA TX-15-0004: Approval Document (approved June 5, 2015, effective April 1, 2015)#
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Table of Contents
State/Territory Name: Texas State Plan Amendment (SPA) #: 15-04 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved SPA Page
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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Dallas Regional Office 1301 Young Street, Suite 833 Dallas, Texas 75202
DIVISION OF MEDICAID & CHILDREN’S HEALTH - REGION VI
June 5, 2015
Our Reference: SPA TX 15-004
Ms. Kay Ghahremani State Medicaid/CHIP Director Health and Human Services Commission Post Office Box 13247 Mail Code H100 Austin, Texas 78711
Dear Ms. Ghahremani:
We have reviewed the State’s proposed amendment to the Texas State Plan submitted under Transmittal Number 15-004, dated April 13, 2015. This state plan amendment describes the eligibility requirements for Medicaid as it relates to marriage.
Based on the information submitted, we have approved the amendment for incorporation into the official Texas State Plan with an effective date change of April 1, 2015. A copy of the CMS-179 and approved plan pages are enclosed with this letter.
If you have questions, please contact Cheryl Rupley at (214) 767-6278.
Sincerely,
Bill Brooks
Associate Regional Administrator
cc: Becky Brownlee, Policy Development Support
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LA Redacted SPAs Page 2
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State: Texas Date Received: 13 April, 2015 Date Approved: 5 June, 2015 Date Effective: 1 April, 2015 Transmittal Number: TX 15-0004 Transmittal Number: TX 15-0004
Date Approved: 5 June, 2015 Date Effective: 1 April, 2015 Supersedes TN: New Page
(spa)(tx-15-026)(approval-document)Texas Medicaid SPA TX-15-026: Approval Document (approved January 12, 2016, effective September 1, 2015)#
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Table of Contents
State/Territory Name: Texas State Plan Amendment (SPA) #: 15-0026 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Superseding Page Listing 4) Approved SPA Pages
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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Dallas Regional Office 1301 Young Street, Suite 833 Dallas, Texas 75202
DIVISION OF MEDICAID & CHILDREN’S HEALTH - REGION VI
January 12, 2016
Our Reference: SPA TX 15-026
Mr. Gary Jessee State Medicaid/CHIP Director Health and Human Services Commission Post Office Box 13247 Mail Code H100 Austin, Texas 78711
Dear Mr. Jessee:
We have reviewed the State’s proposed amendment to the Texas State Plan submitted under Transmittal Number 15-026 dated September 23, 2015. This state plan amendment implements changes to the outpatient hospital services reimbursement methodology. These reimbursement changes include:
• Increasing general outpatient reimbursements to rural hospitals such that final payments do not exceed 100 percent of cost. • Increasing reimbursement to rural hospitals for outpatient emergency department services that do not qualify as emergency visits such that final payments do not exceed 65 percent of cost. • Removing references to hospitals in Rockwall County due to the expiration of the hospitals' transition from rural to urban classification. • Creating rural hospital add-ons to the outpatient hospital imaging services fee schedule
Based on the information submitted, we have approved the amendment for incorporation into the official Texas State Plan with an effective date change of September 1, 2015. A copy of the CMS- 179 and approved plan pages are enclosed with this letter.
If you have questions, please contact Cheryl Rupley at (214) 767-6278.
Sincerely,
Bill Brooks
Associate Regional Administrator
cc: Dana Williamson, Manager, Policy Development Support
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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE AND MEDICAID SERVICES TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE AND MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Circle One): 1. TRANSMITTAL NUMBER: 15-026 FORM APPROVED OMB NO 0938-0193 2. STATE: TEXAS 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED EFFECTIVE DATE: September 1, 2015 D NEW STATE PLAN D AMENDMENT TO BE CONSIDERED AS NEW PLAN ~ AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: SEE ATTACHMENT a. FFY 2015 $ 1,383,790 42 CFR §§440.20, .210(a)(1), .220 b. FFY2016 $16,102,655 c. FFY2017 $17,002,308 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): SEE ATTACHMENT TO BLOCKS 8 & 9 SEE ATTACHMENT TO BLOCKS 8 & 9 10. SUBJECT OF AMENDMENT: This amendment implements changes to the outpatient hospital services reimbursement methodology for rural hospitals. 11. GOVERNOR'S REVIEW (Check One): D GOVERNOR'S OFFICE REPORTED NO COMMENT ~ OTHER, AS SPECIFIED: Sent to Governor's Office this date. Comments, if any, will be forwarded upon receipt. D COMMENTS OF GOVERNOR'S OFFICE ENCLOSED D NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12 L: 16. RETURN TO: Kay Ghahremani 13. TYPED Nb(ME: State Medicaid Director Kay Ghahremani Post Office Box 13247; MC H-100 14. TITLE: Austin, Texas 78711 State Medicaid Director 15. DATE SUBMITTED: September 23, 2015 FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: 18. DATE APPROVED: PLAN APPROVED- ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 20. SIGNATURE OF REGIONAL OFFICIAL: 21. TYPED NAME: 22. TITLE: 23. REMARKS: ~. FORM CMS -179 (07-92) 23 September, 2015 1 September, 2015 BILL BROOKS 12 January, 2016 Associate Regional Administrator Division Of Medicaid & Children's Health
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Attachment to Blocks 8 & 9 to CMS Form 179
Transmittal Number 15-026
Number of the
Number of the Superseded Plan Section or Attachment
Plan Section or Attachment
Attachment 4.19-B Attachment 4.19-B Page 2 Page 2 (TN 13-041) Page 2a Page 2a (TN 13-041) Page 2a.1 Page 2a.1 (TN 13-041) Page 2a.2 Page 2a.2 (TN 13-041)
State: Texas Date Received: 9-23-2015 Date Approved: 1-12-2016 Date Effective: 9-1-2015 Transmittal Number: 15-0026
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State of Texas Attachment 4.19-B Page 2 4. Outpatient Hospital Services
TN: ____________ Approval Date: ____________ Effective Date: ____________ Supersedes TN: ____________ (a) Introduction. The Health and Human Services Commission (HHSC) or its designee reimburses outpatient hospital services under the reimbursement methodology described in this section. Except as described in subsections (c) and (d) of this section, HHSC will reimburse for outpatient hospital services based on a percentage of allowable charges and an outpatient interim rate. (b) Interim reimbursement. (1) HHSC will determine a percentage of allowable charges, which are charges for covered Medicaid services determined through claims adjudication. (A) For high volume providers that received Medicaid outpatient payments equaling at least $200,000 during calendar year 2004. (i) For children's hospitals and state-owned teaching hospitals as defined in Attachment 4.19-A, pages 1a and 3, respectively, of the Texas Medicaid State Plan (relating to Inpatient Hospital Reimbursement), the percentage of allowable charges is 76.03 percent. (ii) For rural hospitals as defined in Attachment 4.19-A of the Texas Medicaid State Plan, page 3, the percentage of allowable charges is 100 percent. (iii) For all other providers, the percentage of allowable charges is 72.00 percent. (B) For all providers not considered high volume providers as determined in paragraph (1)(A) of this subsection. (i) For children's hospitals and state-owned teaching hospitals as defined in Attachment 4.19-A, pages 1a and 3, respectively, of the Texas Medicaid State Plan , the percentage of allowable charges is 72.27 percent. State: Texas Date Received: 9-23-2015 Date Approved: 1-12-2016 Date Effective: 9-1-2015 Transmittal Number: 15-0026 9-1-2015 1-12-2016 15-0026 13-0041
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State of Texas Attachment 4.19-B Page 2a 4. Outpatient Hospital Services, continued
TN: ____________ Approval Date: ____________ Effective Date: ____________ Supersedes TN: ____________ (ii) For rural hospitals as defined in Attachment 4.19-A, page 3, of the Texas Medicaid State Plan, the percentage of allowable charges is 100 percent. (iii) For all other providers, the percentage of allowable charges is 68.44 percent. (C) For outpatient emergency department (ED) services that do not qualify as emergency visits, which are listed in the Texas Medicaid Provider Procedures Manual and other updates on the claims administrator's website, HHSC will reimburse: (i) rural hospitals an amount not to exceed 65.00 percent of allowable charges after application of the methodology in paragraph (2)(C) of this section, which will result in a payment that does not exceed 65.00 percent of allowable cost, for claims with a date of service on or after September 1, 2015; and (ii) all other hospitals, a flat fee set at a percentage of the Medicaid acute care physician office visit amount for adults. (2) HHSC will determine an outpatient interim rate for each hospital, which is the ratio of Medicaid allowable outpatient costs to Medicaid allowable outpatient charges derived from the hospital's Medicaid cost report. (A) For a hospital with at least one tentative cost report settlement completed prior to September 1, 2013, the interim rate is the rate in effect on August 31, 2013, except the hospital will be assigned the interim rate calculated upon completion of any future cost report settlement if that interim rate is lower. (B) For a new hospital that does not have at least one tentative cost report settlement completed prior to September 1, 2013, the interim rate is 50 percent until the interim rate is adjusted as follows: (i) If the hospital files a short-period cost report for its first cost report, the hospital will be assigned the interim rate calculated upon completion of the hospital's first tentative cost report settlement. (ii) The hospital will be assigned the interim rate calculated upon completion of the hospital's first full-year tentative cost report settlement. State: Texas Date Received: 9-23-2015 Date Approved: 1-12-2016 Date Effective: 9-1-2015 Transmittal Number: 15-0026 9-1-2015 1-12-2016 15-0026 13-0041
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State of Texas Attachment 4.19-B Page 2a.1 4. Outpatient Hospital Services, continued
TN: ____________ Approval Date: ____________ Effective Date: ____________ Supersedes TN: ____________ (iii) The hospital will retain the interim rate calculated as described in clause (ii) of this subparagraph, except it will be assigned the interim rate calculated upon completion of any future cost report settlement if that interim rate is lower. (C) Interim claim reimbursement is determined by multiplying the amount of a hospital's outpatient allowable charges after applying any reductions to allowable charges made under paragraph (1) of this subsection by the outpatient interim rate in effect on the date of service. (D) Cost settlement. Interim claim reimbursement determined in subparagraph (C) of this paragraph will be cost-settled at both tentative and final audit of a hospital's cost report. The calculation of allowable costs will be determined based on the amount of allowable charges after applying any reductions to allowable charges made under paragraph (1) of this subsection. (i) Interim payments for claims with a date of service prior to September 1, 2013, will be cost settled. (ii) Interim payments for claims with a date of service on or after September 1, 2013, will be included in the cost report interim rate calculation, but will not be adjusted due to cost settlement unless the settlement calculation indicates an overpayment. (iii) HHSC will calculate an interim rate at tentative and final cost settlement for the purposes described in subparagraph (B) of this paragraph. (iv) If a hospital's interim claim reimbursement for all outpatient services, excluding imaging, clinical lab and outpatient emergency department services that do not qualify as emergency visits, for the hospital's fiscal year exceeded the allowable costs for those services, HHSC will recoup the amount paid to the hospital in excess of allowable costs. (v) If a hospital's interim claim reimbursement for all outpatient services, excluding imaging, clinical lab and outpatient emergency department services that do not qualify as emergency visits, for the hospital's fiscal year was less than the allowable costs for those services, HHSC will not make additional payments through cost settlement to the hospital for service dates on or after September 1, 2013. State: Texas Date Received: 9-23-2015 Date Approved: 1-12-2016 Date Effective: 9-1-2015 Transmittal Number: 15-0026 9-1-2015 1-12-2016 15-0026 13-0041
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State of Texas Attachment 4.19-B Page 2a.2 4. Outpatient Hospital Services, continued
TN: ____________ Approval Date: ____________ Effective Date: ____________ Supersedes TN: ____________ (c) Outpatient hospital imaging. (1) For all hospitals except rural hospitals, as defined in Attachment 4.19-A, page 3, of the Texas Medicaid State Plan, outpatient hospital imaging services for claims with a date of service on or after September 1, 2013, are not reimbursed under the outpatient reimbursement methodology described in subsection (b) of this section. Outpatient hospital imaging services are reimbursed according to an outpatient hospital imaging service fee schedule that is based on a percentage of the Medicare fee schedule for similar services. If a resulting fee for a service provided to any Medicaid beneficiary is greater than 125 percent of the Medicaid adult acute care fee for a similar service, the fee is reduced to 125 percent of the Medicaid adult acute care fee. (2) For rural hospitals, outpatient hospital imaging services for claims with a date of service on or after September 1, 2015, are reimbursed according to the outpatient hospital imaging service fee schedule calculated in paragraph (1) of this subsection plus add-on amounts as follows: (A) for procedure codes with a fee calculated under paragraph (1) of this subsection that is less than or equal to $80.00, the rural hospital add-on amount is $3.00; (B) for procedure codes with a fee calculated under paragraph (1) of this subsection that is greater than $80.00 and less than or equal to $150.00, the rural hospital add-on amount is $8.00; (C) for procedure codes with a fee calculated under paragraph (1) of this subsection that is greater than $150.00 and less than or equal to $300.00, the rural hospital add-on amount is $15.00; and (D) for procedure codes with a fee calculated under paragraph (1) of this subsection that is greater than $300.00, the rural hospital add-on amount is $32.00. 5. Hospital Ambulatory Surgical Centers (HASC) are reimbursed in accordance with Attachment 4.19-B, page 7(f), relating to the reimbursement methodology for Ambulatory Surgical Centers (ASCs).
6-7. Intentionally left blank. State: Texas Date Received: 9-23-2015 Date Approved: 1-12-2016 Date Effective: 9-1-2015 Transmittal Number: 15-0026 15-0026 1-12-2016 9-1-2015 13-0041
(spa)(tx-15-033)(approval-document)Texas Medicaid SPA TX-15-033: Approval Document (approved January 20, 2016, effective October 1, 2015)#
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Table of Contents
State/Territory Name: Texas State Plan Amendment (SPA) #: 15-0033 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Superseding Page Listing 4) Approved SPA Pages
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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Dallas Regional Office 1301 Young Street, Suite 833 Dallas, Texas 75202
DIVISION OF MEDICAID & CHILDREN’S HEALTH - REGION VI
January 20, 2016
Our Reference: SPA TX 15-033
Mr. Gary Jessee State Medicaid/CHIP Director Health and Human Services Commission Post Office Box 13247 Mail Code H100 Austin, Texas 78711
Dear Mr. Jessee:
We have reviewed the State’s proposed amendment to the Texas State Plan submitted under Transmittal Number 15-033 dated December 17, 2015. This state plan amendment updates the physicians and other practitioners’ fee schedule and changes the reimbursement methodology for physician-administered drugs and biological products when a new national procedure code is assigned.
Based on the information submitted, we have approved the amendment for incorporation into the official Texas State Plan with an effective date change of October 1, 2015. A copy of the CMS-179 and approved plan pages are enclosed with this letter.
If you have questions, please contact Cheryl Rupley at (214) 767-6278.
Sincerely,
Bill Brooks
Associate Regional Administrator
cc: Dana Williamson, Manager, Policy Development Support
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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE AND MEDICAID SERVICES TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE AND MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Circle One): 1. TRANSMITTAL NUMBER: 15-033 FORM APPROVED OMB NO 0938-0193 2. STATE: TEXAS 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED EFFECTIVE DATE: October 1, 2015 D NEW STATE PLAN D AMENDMENT TO BE CONSIDERED AS NEW PLAN 181 AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittalforeach amendment) 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: SEE ATTACHMENT Social Security Act §1902(a)(30); 42 CFR §447.201 a. FFY 2016 $203,719 b. FFY2017 $226,907 c. FFY2018 $237,312 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (If Applicable): SEE ATTACHMENT TO BLOCKS 8 & 9 SEE ATTACHMENT TO BLOCKS 8 & 9 10. SUBJECT OF AMENDMENT: The proposed amendment updates the physicians' and other practitioners' fee schedules and changes the reimbursement methodology for physician-administered drugs and biological products when a new national procedure code is assigned. 11. GOVERNOR'S REVIEW (Check One): D GOVERNOR'S OFFICE REPORTED NO COMMENT 181 OTHER, AS SPECIFIED: Sent to Governor's Office this date. Comments, if any, will be forwarded upon receipt. D COMMENTS OF GOV~#R'S OFFICE ENCLOSED D NO REPLY RE9¢ED ~1HIN 45 DAYS OF SUBMITTAL 12~~ENCYOFFICIAL: 16. RETURN TO: I' 'l// Gary Jessee 13.TYPrAW/ State Medicaid Director GaryJess e Post Office Box 13247, MC: H-100 Austin, Texas 78711 14. TITLE: v State Medicaid Director 15. DATE SUBMITTED: December 17,2015 FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: 18. DATE APPROVED: PLAN APPROVED- ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 20. SIGNATURE OF REGIONAL OFFICIAL: 21. TYPED NAME: 22. TITLE: 23. REMARKS: FORM CMS -179 (07-92) 17 December, 2015 20 January, 2016 1 October, 2015 BILL BROOKS ASSOCIATE REGIONAL ADMINISTRATOR DIVISION OF MEDICAID AND CHILDREN'S HEALTH
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Attachment to Blocks 8 & 9 of CMS Form 179
Transmittal Number 15-033
Number of the Number of the Superseded Plan Section or Attachment Plan Section or Attachment
Attachment 4.19-B Attachment 4.19-B
Page 1a.3
Page 1a.3 (TN 15-021)
Page 25i
Page 25i (TN 15-015)
State: Texas Date Received: 12-17-2015 Date Approved: 1-20-2016 Date Effective: 10-1-2015 Transmittal Number: TX 15-0033
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State of Texas Attachment 4.19-B Page 1a.3 1. Physicians and Other Practitioners (continued)
TN: ____________ Approval Date: ____________ Effective Date: ____________ Supersedes TN: ____________ (f) When a procedure code is nationally discontinued, a replacement procedure code is nationally assigned for the discontinued procedure code, and Medicaid implements the replacement procedure code, a state plan amendment will not be submitted since the fee for the service has not changed. (g) To ensure access to care and prompt provider reimbursement, when a new national procedure code is assigned to a physician-administered drug or biological product, a preliminary reimbursement rate will be established by the Texas Health and Human Services Commission (HHSC) based on the published Medicare reimbursement rate or the average wholesale price (AWP) in the absence of a Medicare reimbursement rate for the procedure code or the comparable procedure code. In accordance with 42 CFR §447.205(b)(1), a public notice and state plan amendment will not be submitted for this preliminary reimbursement rate. This will allow the new procedure code to be payable as the reimbursement process is completed with a public notice published and a state plan amendment submitted. (h) All fee schedules are available through the agency’s website, as outlined on Attachment 4.19-B, page 1. (i) The agency’s fee schedule was revised with new fees for services provided by physicians and other practitioners affiliated with tuberculosis clinics or employed by tuberculosis clinics effective October 1, 2011, and this fee schedule was posted on the agency’s website on October 7, 2011. (j) The agency’s fee schedule was revised with new fees for physicians effective October 1, 2015, and this fee schedule was posted on the agency’s website on October 15, 2015. State: Texas Date Received: 12-17-2015 Date Approved: 1-20-2016 Date Effective: 10-1-2015 Transmittal Number: TX 15-0033 15-0021 TX 15-0033 1-20-16 10-1-15
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State of Texas Attachment 4.19-B
Page 25i 32. Reimbursement Methodologies for Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services - continued
TN: ____________ Approval Date: ____________ Effective Date: ____________ Supersedes TN: ____________ (10) Physician services (a) Services reimbursable only for Medicaid-eligible clients under age 21 include: (1) Vaccines not covered by the Texas Vaccines for Children Program (TVCP) for clients under age 21 which are reimbursed as accessed- based fees in accordance with Item 1 of Attachment 4.19-B, relating to the reimbursement methodology for physicians and certain other practitioners. Payments based on a fee schedule are made for these services. (2) Services delivered by school districts, in accordance with Item 32(17) of Attachment 4.19-B, relating to the reimbursement methodology for School Health and Related Services (SHARS). (b) All fee schedules are available through the agency's website as outlined on Attachment 4.19-B, page 1. (c) The agency's fee schedule was revised with new fees for EPSDT physician services effective October 1, 2015. The fee schedule will be posted on the agency website on October 15, 2015. State: Texas Date Received: 12-17-2015 Date Approved: 1-20-2016 Date Effective: 10-1-2015 Transmittal Number: TX 15-0033 15-0015 TX 15-0033 1-20-16 10-1-15
(spa)(tx-16-0001)(approval-document)Texas Medicaid SPA TX-16-0001: Approval Document (approved December 18, 2017, effective July 1, 2016)#
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'lable of Contents State/'l'en'itory Name:'l'exas Statc Platr Amendment (SPA) /l: I 6-0001 'I'his file contains the fbllou,ing clocuments in the ordel listed l) Approval Letter 2) CMS 179 ltrorm 3) Su¡rerseding Page Listing 4) Approvecl Page
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lllìl';\R Iñ1llN I OlI l-llì;^l-ìII & llUi\i,\N Slillì\rl(}.S r ì rìl, r'\ l(rr \lrrli...rrr'¡: Nlt Jr.¡iJ SL rr ir'r's Da lLrs llc¡iiorraì Offico 1301 Yourìil 5tr1\.1, 5uikr 33.i l)ailas, li'ras 75202 €mÆw afNllitì5fcrrítDì(n{L.\ r,l)lcÁlt)s r\¡lcIs c(rNsot¡lruM ¡oR ÀlEÛtcr\lD & clllt l_¡[Ét\1,!ì tl¡^rl$ (lF¡:n,{lroN5 r)lvrsr()N ôF MfiDlc,\tD & CHlt I)RtìN's HE^.I- R Iì':I llN \/t l)cccnrbcl I tì. 201 7 {)ur lLefcrcncc: SPÀ ]'X l6-0001 Ms. Stc phanic Muth Slatc lvl cd icaid I)ircctor' 'I'cxas [Ìea]th aÍì(l Ilunrân Scr-r'iccs (lonrlnissiott N4 ail Codc: Il1 00 Ir'.O. llox I 3247 .,\Lrslin. 'lìcxas 7tl7 I l l.)cal Ms. Muth Wc hat'c rcvict'ccl thc St¿ì1.c's proposcd amcucfir'ìellt to your Mcclìcaìcl Statc l)l¡n sul'rmittcd uncler' Ir¿rnsrlitlal Nunrber ('l'N) l6-0001. clated l\4 a¡' 20,201(t. l'his ¡tnencltncnl cxpiìr.ìds thc nc'ccls- Lrascd c ligibilì11' clile lia ibr lhcr Ì lorlc a rrcl (iouun u:r ity-lìasc.l Serviccs Adult Nlen1âl I Icâltìr (IICllS-AMII) I9I5(i)¡rlogranrsto jncludc âclults with a dia g:losrs o1' ¡ sct ious lì1c nt¿ll rllncss ( SI\41) r.l ho havc ¿r histor'). ol' psyohiatric crisis and lepcalcd dìschalges li'onr cort'eclior¿ fàciìit.jes" ¿rs q cll as adults uith a clìagnosis o1'SiVf I u,ho har,c a ¡rattcrn of'elltergcllcl tlcpartnrcn tu1ìlìzÍttiorl. l Lrc ¡rlo¡rosccl ¿rnrcndrncltt a.lso rolrovcs lhc onc to thrcc lrcd lìnrit lul Iror¡es oq,nccl or le¿ìsed b¡, an llClìS-AlVlll proviclcr'¿ìnd approvcd b1' the Statc âncì rcviscs thc conl-lict of inLorcst stanclalcls to nTiligate confìicL ol'irttercst il'tllc indìr'icluaì per{blnring lhc íìsscssnlcnt u'or'l<s lbr thc providcr of'last l'csort, IJascd on thc infblnlation subrnittcd, r,r,o havc a.p¡rloverl thc ¿rurcncfincnl lòr incolpolaLior inlo thc ollìcíal 'l'cx¿rs slatL'ì)lâu r.viLh an cflèctivc datr: olJuì¡. 1.20l(i, as tcqucstccl. À cop¡ o1-('N'lS I7t) lìrillt r., rrcll :ìs thc ilplì¡)\c(l ¡li:n ¡rrrcs rlc inelLttl.'cì \\'itlì llljs l. tlcr. lf'you havc any cplcstions please cor.ì{act Irord lllunt o1'n'r¡,. stafì-, Mr. l}lun1 nra¡' bc rcachcd at (2 l4) 767-6381 ol by e-nraiJ at liül lì!!&c!u]ùlg(ìt S inccrcl¡,. Bill llroolis Associate Iìogional Aclnlinistlator' cc: D¿na Willianrson. ì\4anaget'. Polìcy l)cvclopttrcttt Su¡rport
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DEPARTMENT OF HEALTH AND FORM APPROVED I, TRANSMITTAL NUN4BER: 16.0001 2, STATE: IEXAS TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FoR: cENTERS FOR MEDICARE AND MEDICAID SERVICES 3. PROGRAM IÞENTIFICATION: TITLE XIX OF THE SOCIAL SÉCURITY ACT (MEDICAID) AMENDMENT tr AMENDI\4ENT To BE CoNSIDERED AS NEW PLAN ADI\¡INISTRATOR CENTERS FOR MEDICARE AND MEDICAID SERVICES SERVICES 5, TYPE OF PLAN (C¡rçle One)i tr NEW STATÊ PLAN COMPLETE BLOCKS 6 THRU 10 lF THIS lS AN AMENDMENT (Seoarate Transmittalfot each amendmenl) 6. FEDERAL STAÏUTE/REGULATION CITATION: SsA S rsl5(¡), 42 c.F.R. S 440.180(d)(2), ¡t40.182(cXB) 7. FEDERAL BUDGET IMPACT: a. FFY 2016 b. FFY 2017 c. FFY 2018 $ 1,643,316 $ 13,674,530 $ 14,835,0S5 SEE ATTACHMENT 8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: SEE AfiACHMENT TO BLOCKS 8 & 9 9, PAGE NUMBER OF THE SUPERSEDEI] PLAN SEC I ION OR AITACHMENT (lf Appl¡caþle): SEE AITACHMENÎ TO BLOCKS 8 & 9 10. SUBJECT QF AMEND¡/ENT: The purpose of th¡s amendment ¡s to expand the needs-based ellgib¡lity cr¡teria for th€ Home and Community-Based Serv¡ces-Adult Mental Health (HcBS-AMH) 1915(l) program to ¡ncludê adults wlth a dlagnosís of a ser¡ous mental illness (SMl) vyho have a bìstory of psychiatric cris¡s and repeated d¡scharges from correctional facil¡ties, as well as adults with a diagnos¡s of SMI who háve á patlern ofemergèncy department util¡zation. The proposed amendment also removes the one to three bed l¡mit for homes owned or leaÊed by an HCBS-AMH prov¡der and approved by the State and rev¡ses the conflict of interest standards to mltlgate confllct of interest if the ind¡v¡dual pêrform¡ng the assessment works for the provider of last resort. a oTHER, AS SPECIFIED: Sent to Govefnor',s Offrce this date. Comments, ¡f any, w¡ll be fon^/a[ded upon rêce¡pt. 1 1 . GOVERNOR'S REVIEW (Check One.l: Ú GoVERNoR'S oFFICE REPORTED NO COMMENT ¡ coMMENTS OF GOVf&.|OR'9OFFTCE ENCLOSED tr NO REPLY RECEWøWfiÞIÑ 45 DAYS OF SUBMITTAL 12. Mdy 20, 2016 State Gary tJ. Gary Jessee State Medica¡d Director Post Office Box 13247, MC; H.100 Austin, Texãs 78711 18. DATE APPROVED: I)ccc¡Ïbcr l8_ 20t7 17. DATE RECEIVED: Mar, 20. 20 ì (r 19. EFFECTIVE DATE OF APPROVED MATERIAL; 'lLtl;' Ì ' 2016 Associatc Iìcgìonnl Adnl in istlatot Divisior ol N'ledicaid anrl Chiidtcn's I.le allh 22. TtfLE: lJ ill Fl ooks 21. ryPED NAME: 23. RENi'ARKS: FORM CMS - 179 (07-92)
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Attachment to Blocks I & I of GMS Form 179 Transmittal Number I 6-0001 Number of the Plan Section or Attachment Number of the Superseded Plan Section or Attachmellt Attachment 3, 1-i Page 4 Page 5 Page 6 Page 7 Page B Page 9 Page 9a Page 10 Page 11 Page 12 Page 13 Page 14 Page 15 N/A Blank Page 29 Page 30 Page 35 Page 48 Page 53 Page 57 Page 65 Page 66 Page 67 Page 68 Page 79 Page 82 Attachment 3.1 -i Page 4 (TN 14-014) Page 5 (ïN 14-014) Page 6 (TN 14-014) PageT (TN 14-014) Page B (TN 14-014) Pase 9 (TN 14-014) N/A - New Page Page 10 (TN 14-014) Page 11 (TN 14-014) Page 12 (TN 14-014) Page 13 (TN 14-014) Page 14 (TN 14-014) Page 15 (TN 14-014) Page '16 (TN 14-014) Page 29 (TN 14-014) Page 30 (TN 14-014) Page 35 (TN 14-014) Page 48 (TN 14-014) Page 53 (TN 14-014) Page 57 (TN 14-014) Page 65 (TN 14-014) Page 66 (TN 14-014) Page 67 (TN 14-014) Page 68 (TN 14-014) Page 79 (TN 14-014) Page 82 (TN 14-014) (ixas l.liìte lìecÕiv(:d: May 20, 20'1ö üate App rovo(l: DÉrcenrber 18,2017 Eflrctivê Daler .luly '1, 20'16 l'r¿ìn smÍtlâ11 NurÌrb{ìr 16-0001
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Strì1c: l'cxâs I'lffcctivc: .s ì9I5(i) Sratc l'lan I ICUS Adr¡lt Mental l.lca lth (llCBS-ANltl) ,{ ¡rpluvecl: Supcrsedcs: St.a1c P[ar] A (1iìch rneni -ì.1--i l)agc 4 (ll¡'thecking tlrtt.fõllot+'ing lt<Ðtcs lhe Stdte ui.\t.u c',\ lhol): 4. EI Colllict ol llrtclcst Slandalds. Ihe Statc assules thÈ inclcpcndcllce of pclsons pcrlblnring eviìluâtions, thcsc lì1r'lcti0ìrs are n0t: o lclatecl Lr1, lrlooclorrnariiagetoiheilìdividuâi,oran¡.paide.rc3ircr',rl tlrc in<liri,-lt¡¡l o {inanciall-r rcsponsible fìl thc incliviLlual , cnìÞowcred to rnalic lìnancial ol health-r'elated cfecisÍons on bchall'of Lhc individLral . ¡l'ovidcrs ol Stütc PIan ll('lls lbr the individuaì. ol tìrosc \vho ìra\rc inl.clcsl iu or arc cmpìo¡'cd b¡ a ¡:)¡ovidcr of'Stalc l)ìâr llCflS; exccpt, irL lhc op{i(,n ol lhc Sla{c. rvìrcrr ¡r|ovitlcrs a|e liveu respolsibili{v to pcllìrìn'ì1 iìsscss]]lcrìfs ünrl pl¿ns ul'c-a|e bccause sucìì iìdividuaìs arc thc onl) $ illiìg and qu0lilìcd cirLitt i a ¡ieogla¡rìric alca. and thc Stalc devises conflictof inl.oìcs1 prolcctions. ll/ th?,Stdta.:lþos(s thi.t r1'ri,'tt rpct:iJi,tlrcconflitttlinto¿.\lprol¿Llion:ithrStat¿ir¡lliDtpl(n..nt); it-y, on 91 (^ll^ iurliviLlu¿l rcct'r'çrt' pl¡us ard lìr iols. io¡ltilii! dcteì rl]in¡1 i(nis. |c¡ls|jÇssl cnijì, i1ttal o[ lh,,ì llìP an,l pesoo- uìllcis rhc), scn'íor' and irr<livkhials cîr¡rlo¡ crl rs thc pr0\,i{lcr ol lâs[ ir ol arc cupkrycil i:;, lhe rec0vcr) 6 Rcrceived: M¡y 20 2016 Allprove d. l-)ecÈülb{ìr 18. 201 / 18,17 l.l¿te: ,lLrly 1 2(]10 S unêrsedes 1'N 14.(1014 D¿idl
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Stale; lcxas rsl9l5(i) State l)lar IlCllS Stâle PIan Allâchnrcnt i,l"i A(hrh ñlcnlal l lealllr (l-ìCllS-1,ìVIH) l'u¡re .i Iil'l'ecl'ive: Âpp{Ì11!: Supcrscdcs: ir ¿rccordancc uith 42 C|lì.li I SLrb¡rart l:. l'rrl mo¡r ancl boa¡'cl ir. SLale I'latr llClBS. 7. EI :NoD-dupl¡câtior of serviccs. S1a1e Pl0n IICUS uilì not bc provic{cc1 to an irclividual at 1hc saìÌ)e 1ir1rc as arìotho' scrvicc lhal is llre sanrc in raLurc ¿llcl sctlpc iegatdlcss ol'sourcc. includin!-l I¡cdcl¿1, stalc. Iocrì. ¿ncl A.pproval llâte: l2^ cntìt¡es. Dale: ,J uly -1. ? 010 nsnr ilial Nurùkror: l6-000'1 Rece¡ve ci lt4ay 20. 2016 Approved: l.lcicû]rlber 18. 201 7 SLrpersr:des'l-N: 1 4'001 4 Püvj<lcr Agcrrcics nnrl rrìay.aJso rnusl ard th; o'l'recoverl, rnanagcr- Änd DSI'IS 0{ slüt'1' wiliidirrìli¿ dhqc( p f0t0\-.l!ry. l tb 1lìe tn 7
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Stâtc: l cxâs Illfèctivc: S ì915(i) S1âtc Plar IlCl'ìS A(lu lt Mcnt{ìl Ilc'alth (llCUS-AMII) St¿ìtc l)l¿ìn Atlaoh mcrt l. l-. j ì'agc 6 A ¡¡rr,rr cr1: S u pel secl cs undupliL:atcd inclividuals s,rrvcd ard thc eslirnâled nurnbcr ol'ìndì\,iduals lìr'the ftrllou'ing ¡ cLrt. sl)ùci1ìcd at N1902(aXl0X^)(ii)(XXll) ol the Social Secr¡ril! Act.) ?. I rìtoruc [-irn its. lI addition 10 provi(linll Statc Plan llCllS to individuals dcsclibeLl in ilenl I above. the Slirlc is also co\'crine, thc oplioìral câlcgoricall), nccd)' elìgibilit)' group of inclivìdrtals Lrntli:r' I902(â)(l0X^)(iiXXXIl.) who are eligìbìe lin lICIIS rrndel rhe nee¡ls-bascd clileli¡ cstatrlìshctl Lr¡lct f915(iXiX^)andlravci|colrelhâtdoesno( cxccecl l-509'i, 01'the lcdcralpovert,r levcl,or\vhoarc eligible lìrllCBSundcrawaiverappr'ovodfbrtheS{alcundc[sectiorI9]5(c).(cl)o(c)orseetìon L l5 lo ¡rr<lvirlc sLrch sclv¡ccs to indjviduals rvhosc inconle docs ìr01 e\cced 3009'; ol'lhc suppìcne;rlal liccUrit) ¡rlcoììrc bcnclìt ratc (âs descril¡ed in ,^t{achrncrìl 3.2Â, lìu¡ìc ll 01'lhc Statc Plân). (llroosc onc: n 'l ììq Slato coycrs all intlividL¡als dcscrìbed in ilcrns 2(a) iìnd l(b) os dcsclibctl ir ^(lachrrlù'r{ L)-,\ L'l'tlrc \litle I'lrtll. Ploicctcd Nurnllcl oI l]rdnÞlicatcd lndividuals l'o llc Scrvcd Aruually. (,\l).,. ¡I.i|.1õt ),cdr ott¿. )'eur.;2-5 ttptiontI): Ânn ual l)cr'ìod lironl lo P|r.ricctcd Nunrbcr- o1' PaIt icipanls Yr:¡r l tlo l:?o i-s 08/l.rt0ló,':r. IÃ1i1ot6 .r' ós/'r rrol T ,,:.,',.' tl¡it n.o,il ' rn8i3l /2018 ', '75û. 9fi 1,,10I I 08il lÐ019 :': . iio. 9,î1./l0lq .08i:ì t,'20?0. ' ì.,.i '15t) 0f of H :l hc SIâte covers onìy the fÌrllon'irg gloLtp ìnclividr-r¡is descljLrcd belo\\'as spccilìcd in ,4llach¡Tìenl1.2-A ol'1hc Slale Plan. Choose (a) ()I (b): incolnc 1lrât docs not crceed 150'1,ô ol lhe li'dct irl povet l¡, lcvcl, and rvìll recejve I9l-s(i) serviocs. (b) tr . ,t.lndividLr¿rls rvho woLtltl rnect thc crilcriâ f'or Lì l!)15(c) or I I l5 n'ait'el rnd u'lrosc il'lconrc rlocs not excced:i{)0')ó ol'thc supplenrelltal sccLI i1,v- incotnc bcnclìl I¡ìtc. Conìplclc (i) nnil:îr (ii) l N Nrimlrer: 16-000'1 Supersedes -l N: 14-0014 Apprcv¿rl Date : 12-1 8-1 '/ Lffective D¿ile: 07-01-.16 lSìte tc. fl r ir., l['tato l.c,-r lvF.i(l IVI ry' '0 ?0 ltJ Itlalo ¡,¡rll'v,.,1 1r,.,.1. ìrl. ', ìu 20i, lIffc'r;tivc l]ir[, ,JLrlV ] l(r1iì I l, ¡,rc,irllr1 Nl' ù,r1, ,i lr. r1llr11
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Slolc: l'cx¿rs I: I lcct ivc: (\ l9l5(i) State I'lar IlCllS Aclu lt Nicntaì Ilealth (ll(lllS-,AN4ll) Ap¡rlovccl: Supelscdes: S1¿rtc I)la:l Attachmùrt -ì.I i Pa¡:.c 7 i. ([ Spccil-v thc ì915(c) W¡ive r'lWairels Cl\4S l]ase ('onurì Nur¡bcr'.'Nunrbels 1ìrr' a rrc1.'or \\'hicir lhe irdiviclual uoulcl be e l ii. n Sl)cÇi['thcnarnc(s)oinurnber'(s)01']hcllf5rvuivcr(s)l()r\\Jriclìthe irdiviciuaIu'oLrld bc b Ie: 3 MIt l hc Stalc' docs lol pr ovrclc Statc plau I lC'BS 1o thc nìc(jìcall¡' nccd¡,' r l.hc Sla1c ¡.r|ovirlcs Slalc ¡rlar llOIlS 10 thè rneclicall¡'nccd1'. lf;L,lt:t.l on(). l- I'he Statc elcctslo disre!..âr-d the reqLìircìrlerls scclion oJ'ft02(âXl0XCXiXlll) ol theSocial Sccurìt¡,r\cL rcliiting 1o cotnrrrìif) incorne ancì rcsclurcc rLrles 1ìr'thc rnctlicaJl¡,rreecJ¡. Whcn ¿ì slatc nrâl(cs thìl clcclion. nredicaììv necrl¡' indivicÌuals leccrr,c only l9 I 5(i) selvices. ',:: 'l'hc Statc docs ìror cìcct1o disrcgarrl thc reqLrilerncnls.,rt scclioìr 1902(ü)(l0XC)(i)(lll)oirhc Social Sccrìrit! ^c1. ht¡o ex¿.ì$ Dale. 12,'18 17 L:ffedive Dakì: 07-01-16 l)ate [ìíic$]vÈd: l\¡ày 20, 2ù16 Dats Approvr,rcl: l)ecflrnher 18. ;ì011 [-Tîeclive Daic ..]Lrly 1 2010 .l N: l4-0014 Nìrnrhr'lr 1tì-0001
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S(fllc: lùxâs lìl'lèctivc: .s I9l5(i) Slâ.I.c l'lar llCl)S Adrì11 Mcnt¡l I lealth (llCUS-^MIl) St¿ìtc Itlarì Altachnrc:rt -1.I -i l)age 8 Ap¡r'ovcd Sr¡nelscdcs llcspo sibilit¡'lìrr Pcrloüning lilr,¿lu¡rtions / Iìee'r'âl0afions, Iiligibilit¡. fbr rhe Stftc Plan ll('llS bcnclì1 rDL¡st bc rletcÍmjnc n hethÙ applicanls afe cÌigiblc Ib| thc Slatc Pl¿rr l lClllS benclìf flr'c ¡rcrlìrnrcd ls(leL¡ on(). o. I)irccll)' by thc ñlcdicaid agcrìc! o. B\, ùhùr (y)¿.ti' .!'tut.. rt:!:nL't: ()t etllit),unLl(r' L()nlnkl\1'¡tlt lhe '\l(Ilt' \'l((litqid dg(r1c.\:)l DSIìS il¿f'f or ¿dìtr¿ct<ir:i rvho are Lió1.þ!diders of litl.BS-AMll selvices rvill conLlucr the in(ìepenilent evalu¿tiotrs ariâ iee\'âlùations. DS¡ÌS is ¡ot íLntl w ill lot bccirnle rrì I ìLllls pùvitler: ln ¿cldition. DSIIS will airnúally revierv.c¿iìrtractors cuip]et'¡¡g eV.âhj¿ttjrÐs¡ eevfllur¡tjurs to elìsure ihat the)' do not h¿tvt ir collflict ¡f iìrßìÈ.st äncl'âÌe not acirniniSìratively unclei the coìrh olldiiection of ¡ piovirìer r+ho is on lhe lr,rrrt,l'ici:r¡r''s IRl' arì ìgcnt 1lìat is irrdcpcrrrlclt ancl c¡ualilìcd. 'lhcrc ale quiììilìcatiols 11hat arc tcason¡bì)' reliìtcd lo pcrlnrììirì! lì('llS. r"57;¡¡á.' qrr a lifì cttt iotts) nccds,t¡asccl S{île Plûn llClìS cfigibilit} cIileria ¿rncl an-\ iustlurnco{(s) usccì to rrritltc lhis clclcÍ:riDaiion. il'thc r-ccv¿liuî1ioll ¡rroocss dillils fÌorr lhc cvaluâtion ptoccss, dcsct ibc tlte tlillèrcnccs: using tlr!' Arlult Nceds înd Stlclllllhs ^sscss¡]tjrìl (^NSA I lo fìrnctional eecls and deter¡n ¡ne rvhether an individua I maOls the needs-Lrased ICBS ']ligibi lit)' c!fl Lef1i1. Critcria evàluâted USlrìg lhe ANSA .iirçlLrclc behavioro Lhe¿lth nee.ds, Iilt domain 1ìrnctìoning (iniluclinli ¿rssqssrnert livalualions ancl reevaluations oleligibilit¡; fhr I ICBS o1' ADl,s ancl IADLs). and lìrnctiora neecLs rvil be conc[¡ctr¡cl seLvrces. ìfox¿ts ll6ce¡vcd lvl¿ry 20. 201 6 Appr)ved l:)*ceßrÞrìr I I 201 I --a <locuurented cornpetenc¡, ilt Dapadrncnl 01'St te I lerlth ([¡ I a ¿;it{j accrediied fic¡n an a rïinirrüJn lrurnbel oihotus thut is or M{lO in accor'dnnce psychologv, N I'J r¡ber: 6-0001 nersedes ïN 14-0014 Q1 D¡rtc: July f . ilû 16 16 .rñi'l"'l N1,,,ì.1",r' -i^ rlôôr
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S1¿ìtc:'l cxÍrs l'ìfIìctive : -s I f) I 5(i) S ta lo P la n I IC'llS ^dulr l\4ent¿ìl I IL.âlrlì ( I IullS-^MI I ) St¿ìtc Plân ^ttâchrncnt i,I i l)ag1c f) Âpplovcd: S rrnclscdes: 4. @:lltllccvalnal ion Schcclulc. (lh clt.,(kitr thi\ bos tl¡¡t Stuit, 6;1[es Ihul). Neecls-baseci efígibilit¡'tcevaluatiorrs alc corìduc{e(l t lc!ìsl cvÐr )' twclvc fllonlhs. 5. lH'fNccrls-lrascd IICBS Itli!¡ibilily Critcria, (ll.t:clttckirtgtltis htx Ilte Stttl¿ tls.tLU cÍ tltql). Nccds-bascd criteli¿ttuc used lo cvîluale ¿Ìn(l recvâlLrâle \\'ìlcthcr an inclividual is clìuibìc lor Slatc Plan IlCllS. 'ìay AMÈl prrrg lrn ìl thc lrr crises (i.e,, iupntient þsyclriâtlic c¡itelirL) ant'l IN N u r-nbe r' 16-000 1 Approval Dale 12.-1e-17 Etloct¡ve Dãto: 07-01 -1 ô Supersedes'lN 14-0014 lst¡te-l ex;i:, IUat.' fr,:",' u...,.1 lvlôy 20 201(ì llt:tc A¡r¡irovo l lr( !: nL,.. iB. 2(J l,' jlrlfr,cirvr I);rlc .luly 1 2lì1tì ll rrr-rtì/nrtl-ì N rnrh'. r lrì-o(lfl1
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Slî1c: l-e xâs Tèctive : ùs I9l5(ì) Sl.âlc I'l¿Ùr ll(lllS Adu 11 Mcntal I lea I{h (llCIlS-ÂMll) Äp¡rrovcd S r r¡re.r'seilcs: El Necds-lrascd lnstilrt¡onal rrrd W¿ivcr- Critcria, t l)1' c'lttrt:king lhìs bo¡ tha .Stu¡¿ ¿.t.vrrr,.r' /í,r/7: l hcre arc thîn tìlc crilcli¡ abovc lbr |cccìpl ol'Stalc Pl¿rìr l.lclls. Il'thc Slirtc ììas Ìcvised ìns(itrrtiorìal lcvcl of calc 1o rcflccL und c'orrc,';¡tctrrling uort,-,\lt iugÌt1l (x ilcrio./ir er.tult o/ lhc /itll¿11:i¡¡g ¡¡5litulions). Slâtc I)lân At1¿ìclìnlc { ,1.I i Itagc 9it (t. Nunrber: 16 0001 Supersedes l N None .New PâlJe liìtriie. lu.r;:, l[].rte liccÊrvr.,(ì N4âV ?{.1 l0l(i ll)atc, A¡,nr,v',t l]¡'\:. rrf" r lli 2017 lf:lier,trvr I),íij," ,Ju y I ../lr1b_ .
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State: I cxâs l ìl'lìcl ir. c: .s ì f) I 5(i) Statc Pla n lìC13S ArJuiL Mcrt¿l I lcrìth (llOIìS-AMI l) S1¿llc PIan .Atlaclìnìcnt -1. ì-.i l)agc l0 Apploved S L¡Detsecles: Stâlc Plîn I lClìS nccds- based c'ligibilif"r, clitcria NF (ñ NI.'t,OCì."r nlivcrs) lcl,7t lD (¿t tct./ t., [,()Cì $ airers) A pplicablc I lospital* (& I-losl)ilfl I I-OC \r1¡\,ers) 30 co¡sicutivg cìa¡-s or live in:ihô comrnuniiy (fbr lÇFlliIi. rvaivels) ond rÍè¡t ú¡dical neccssily leduir.c¡ncnts (see bclorv) "dcr,elôprncnlaì lùsted befble ltì 1òr of olìnrenlal 1.n diaEroscd disability. nìcàtìs chrûnìc dísàbil¡1y {hûii tq cÒnlirÌrc l-{¿rve ¿ valid diag,nosis as liste<l h the cLrlenl versiorr o{: {he ICD as the pri:rcipal aùiriltit! diagnosis and on9 tlfì!1e Ioìlou'iLrgr. 'þ Outpiìticnt ihcr'¿p,v 0r' païtial.hospitalizuli0rr has beén atlenrplÉrd ánd läilcd {: A ps}'chialrist has cJocunrcntrd rcasor ts rvhy ¿n inpalicnl levcl o1'calc is required, {'lhe client mLr-qt meet at ìcasl onc of'lhc lirllc'wirrg clilcria: '! 'l'hc clicfit is plcscull,v a ala gc'r' tu $ell, . dLjlloushalcd b]' dl leâsi. one of the fblliirrin¡¡: 1i) Recent suicide . . iìtternpl oL active ' suicidal drrr:aÍ.s witlì {r deadly plnn. and thete is . .an absencc of ' r,. 4pplopliatc super vision '.:.' ôr stnrçliìre to lllevÊnl ' stricidç,. l , (ii) lì"cett -sell'- . : îrui.ilative behâvior 01' :: .artivo thrc'af.s ôl'sanre wiih likelihoùcl o{' actjn{i on thc dì1'cal. and therc is an abscncc ofapproprìotc supcrvi.sion 0r stÌ otr.rlc 10 pr'oveni sslÊ mutilâtjon (i.e.- ir]tent;onall)' cuttirilt bullring self), (íii) A.ctíve h¿llucinations or delusìòns tlh-ecting liì<ely to learl to serious self-hâr m tir debili.tating p.svchollomr agii.ntiou or rdtaltlaliou resulting irr a sìgnilìcauù inabilitl, 1Õ for (ìnchrding ÀI)l-"s and lADl-s), or.lìinctional neecfs and slien¡1hs; al!d l'llusl llt Iti :' ^MH) State: fexiìs If¿rtr: fìeceitied; N|ey 20,20lA Di:)te /\pp[ovêd: Decefiber 18. 20 17 Effective Date: .Julv 1. 20'l6 ìupersodes I'N:'1 4-0014 mitt.rl Nurriler 1 6-û001 Approval Dãteì 1
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StaLc: 'lcxas Irll'cct il c: Apploved: S u1:lclsccJcs .s I 9l 5(i) Slare f)lan Ì ICBS Adult Mental l lcalth (H(ìllS-AMII) S1alL-'Plan Alt¿chnre¡f 3. ì -i I)agc 11 dre Rcqu¡r'e àclive m aiì ng -ô alld Nl) lo eorrip)v rvith plescríbecf uredical h¿alth reg¡rìens duc l0 concu[re]ìt ps),chi¿llr¡c . ilhress anil such fàilLrrc lo cornplv is poterrrially haza:dous to lhc lil'c ol'. lhc client. + The cijerit is a cìotrgcl lo 'otlre.r's, 'lhis behavitx tuLrsl bc attribut¿rl)ìc t0 ûre cl ic.rrt's specifi c cliagnosis tììr¡t ùûn bè ¡rdcqr¡ tèly h caled oirl-r,-' ir a hos¡rital se(ling. IìrÌs dangcr is dcrnlonstlalecl b-v one o1' lhe lb I lorvì rr g: ( j) Iì.coent I ifc- lhrcåtcning acliorl or activc hornie.id¡l f htutis . . ol'sanre'vvith a ileaclly . flan, availabilit¡,' . óìlìwleâns to acconrplish thóìian. ûn cl \,ith ,likelihood ol'acting ,,thcltlu'eaL. (iì) Recc.rìl sqriôLrs . .?$siúllive or sa.(listic :behâvior 0r âclivè . thieáfs ofsanre with iikèlihoocl o1'actiug nn the thre¿ìt- ând thP.re 'is ün. ¡b^\ence ol :appropriate supelvision .{x flr..uclurc 1o plcvcni. .à.çsài¡lÌìvc behavior. (iii).^¡livc iralluihrations tT ilelusitììrs dì¡ cctiirg r¡r likèLrt io ]ead to sèr ióLrs' haun oliolhels. . $'l'he clicrif. exhÌbits acù1e onset ol'p"si,cltosis or severe thoú!ht 0n .qrisis,llìat rnêèit iiiÞatieit ps¡,chiatrit: criLel io) itnti I 1i lieen r¡r rnore toÞ ernergeícy clepaniîent (l.rD) vi6¡ls :, ].. '. . . .:ìl N Numbeìr l6-000-l persedes -l N: 14-0014 Date lìeceivÉ-'d: May 20.20']6 Date Approvod. DeúeÌ¡bór 18. 20'i;' EffÊ$live ll¿rte. .lLrly 1 , 20'i6 ApprOväl DatÐ: 7 ^¡y.iN-,1 Nl¡,¡"1-!-.r. I ¡:ì a,rìñ4
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Sl¿ìtù; l'ùx¿ìs l:li'ect ive : .s l9l5(i) St¿tc PIaI IICIIS A(ìUlt l\4crì1âì Ilealth (l lCIlS-¡\l\4II) ¡;¡rlovccl: Su¡rcrse<lcs St¿ìtc Pl¿ìD Atlachmenl .1. l.-i l)agc ì2 ussessnrçnt and Íeatr1ìent ¡rì r sirfe ¿nd tlìçrÍq)eut¡c setting. + J he cliclt hâs iì sovcl'c ealirlg or substtncc iìbuse disordel th¿t rçqrLires,2,1- hour'-a<lay nttdical d)servai ion. snpcrvisi()I). and iülci vciìtioû. * Thc clicvrt exhibits sevclc diso] ícrì(a(jon r){ pclson. placc. or' 1i:rre. * 'lJlc cdient's evalu¿rlion ârìd tÏeatflrent oartlot bc carliccl oul s4lìrly or ellectiveì¡, i tilhel sellings (lue 10 sevelçl\j disnrllfive behiìviors ànd ofher bclr¿r'irrrs, rvhich ln¿ry ¡lso .inr:l ude ph.y-'siciì l, psvchological. or sexLral alluse. * 'l'hc clicnt rcr¡uircs nrcclicâliur lbcrapy or conrplcx tlizLgnosllc cvalualion rl,hc] e thc clicnt's 1o\,ûl ol' lìulúlioninlt prccludcs cooper¿tion with ùúì ûeaûnent regirnen. +-l'he clienf is involved irt tlre leg¿l s),stern, rnânilosts psychiatric syrrp{loms. ârìd is olcìç¡ed ìry a uolll lo undergcr a compr eherisive zrssessment .in.a. liospital setring to cìnrìfi <ìiagnosis and tÍeafilter1 rtéeds.' : AND 'l bi propoied 1feätÌìrùrlt 0r 24-hour-a- r c<¡r.¡ircs ()l)scrv¿ìtion, 'ili!'nt all oJ'lhe ancl and l1r u st 'l Éx:ls ['(ocoivr..d: Mây ?0 tl01[i Al)piÞved Dccerïl)er 18. 2017 07-01 .1ô Datr:r July '1. 20 10 persedes TN: 14-0014
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S1a1c: lcxas I:)llicl ivr¡: S ì91 5(i) Slate Plan I ICIìS Adult. Mcntal l lerìlth (l lC'llS-AMl l) A¡r¡rrovctJ: S upclsedes: Slâ1c Plalì Altachnlcnt -1. ì i Pngc ì3 :. . ii'. ¡'ÂctiVe supelvision by a ps),ch ìa1r'ist wilh the rìppr'ôpri¿te crcderìiiâls. as .dQLÈrrü i¡ed b), thc'l-eras l\4cdical Board (l MB) or o(hcr iìppr0pr'ìiìtc cillit) ; 'F hùplernclllàIi()lr q1ì àrl in ilivicfura lizc,rl fi eulrnelrt lllau; ù I'r'0vision öi'sÊr'\'ice.s thät ceu reasorrably be expected lo iurprove the clicnf's corclition or ¡li cvcnt 1ìrlìrcl rcgre,sslon so fl1Ð1 ¿r lcsser Ievcl ol c¿rc crur hc jnìplcnìenlsd; {' Propo' t catrncnt o1'lhc clicnl's psyc,híalr ic corrclilion rct¡rrilcs scrviccs on an iupndent basís unclu' IIrç.dircclion ofa the. itr.m mtulity do not nreet the.client's leeds. A his(or1 of.inparient aíniissir.rn, iþpeared dischmges lì'on concctirin¿1 li¡cilities. psychiatric clisis, or [Ìf) visits is noL sülïcicnl lo adnrìl an indivir[r¿l l¡ a ;lrd is beìng the It'ì leâsl e¡r,ironrnent årnbLìlät0ìy .rvail¿ble in 7. **f-OC lcvel ol'c¡r'c El:t.tTu gct GroUp(s), I'hc S(atc elccls to tarllct rislgl5(i)StàtePlanllCllSbenelìttoas¡rccifìcptipLrlalioìbased on agc, clisabìli1¡', diagrosis- ancliur cligibilit¡ group. With this clcction. the Stafe will opcritc th¡s progranr l¡r û pcrìod 01'-í )'câr's. ^t lcast 90 clays ¡rrior'10 lhc ûrd 01'this ,5 l.eiìr pcr'¡od, thc Sla1e rnay leclìest benclìt lòr-additional 5-¡car'lcrnrs in acooldance rl'ith l9l-s(iX7XO. \Spc)ri./j: tLtrye t g )rp$)\: ¡c CMS rene\\al ()f lhis LJatÊ Received; llãy 2-Q,2016 TN Number: 16-0001 Supersedes 'l N: 14-00'14 ApprOv¿ìJ Dale. 12-18-17 Ë.fïÉrctíve Dãtet 01,01 -16 Approvcrd: Deocnrber' 18, 201 Dale. ,J( ly 1. 2016 i:. :j,:ì :l Scr.id¡is mçn{âl illness 9þ11eþ-sy; de.rtr'entia, ., l; (r\)
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SIirtc: l c x¿rs [ìl'lòctivc: .sl9l5(i) Sl.âte I'lan IlClìS Stale l)lâr Al.lachurcDl..l.I i Adult Mcntal Llcalth (l lclìS-^l\4lì) l'¿ìgc I "l À¡r¡rlovccl: SLrperscdcs: l Dv..Lt¿ kit¡F tÌ¡c.li ¡l lot1'ìng bo.r¿s lltr Sl(t(t ú\.etrt',\ lhd() ; fl. El Atl,juslnrcnl Authoritl', -l'hc Statc \\'ill notil,y'CN4S ard the public at lcasr ( da¡s bc'folc cxcrcisin-q Ihc oÞtiorì to nrodif,v. nceds-t'asecl cli¡¡ibility clitcria in accortl rvitlr l9l5(i)(l)(l))(ii). 9. EI l{orne andCornnìunity-ll¿ìscdScttings.'lhcSlatcPlaìrìlCIlSbenclìt.uill bc lLrnishctl to indiviclLrals r.r ho ,t.t¡ ¡ t,tI¿,I t .\l,\ ytti,t,tr', 1tt luJt l) l)rsct iJttion ,l lha sclling; und hov' tl¡c| ntect lL'el¿'rul Il()lì,Salliug.s rt:tyuit,tt¡etts. ,tt ll¡e lìn¡¿ o/ .¡uhn¡i,r.tit¡n on¡l it¡ lht: fùluttt. lh¡s suhtnís,¡it¡t¡ .u1Ll ongoinR. ) finlished of $èctions 416,,-51-416,58 will be l esidcnriai setting. I ìCIJS-Al\4l l the alll eÛdrÍe111 optjrì1t/3 iliegràiiot. ancl lI(.ílitate lii accc\ss lù cdnflrìLuily âssutos d¿n àddTesses isà ucfi ndc'pelì,:leuce ablcì ol',seuin-_gs. inc[rdirìg ¡oiì-dj$abilily spocilÌc o¡rtio s and ,: .]:l't ì .' u.t lú ll1. â atd siipport 1ìrllãccess lor irìdivÍduâls lccciving f ICRS-AMII seIY 'rhc 9441.7 I 0..lldividuals hr rcsidenrial sçt1irìp.s hás a righi lo prjv¡]ci, clig,],ì ity nnd locl;ablc doors which lÌorir LJni(s.wi lì have rloofs, of the idua kêys to (hr: Stâfl?cccss 1() Ijving, access. whâl l),pÈs ol'sLâlj'h¿vcr ac!Ìcss, be unÍt is separate.ard (liË1.¡rìcl liofi the and supporl lù contrÒl thcir kl liile, and have tlle lieedour to fìrnrish scïvtces anrl whir provirle.thenr, an cl l eilctYe ì lCllS'AM.l'l .services :' or pri\,àtely.opératecl fìcì is loçalcrilriir þublicty- ritt ¡rlovÌdus ;1ìpatìerìt .,\ny setting ts IoCâled public inslilutiolr; liorn thc llroadcr conrrnrmily Il'ihc: Ìbr enstLl c or olhcr .fblnr. tif' fl1àt land lol ti iiìdìvidual, Services llìrìst be ¡nd {he.realizatìo¡r 0lúe rnar.inrunr exlen1 possible, úeat eaclr natrrra I ancl l¡picral Merlicairl living and tù drÈ ln .' ànd wc¡k garh Approval Dat.ë: 1 2.- 1 L\- 1 / -lN: 14-0014 t:it¿lc tcx:t3 lD¡tr-. H,r.,'rvri,l. N4.ry ..u ..'r116 ll.)ltt,/t¡;¡r,'rv, 'l lir. ,:rl rrr r 'fì 2{l'i ¡ lr:ll,.crrvc,lì.tê llilry 1 ";] ].1:.,
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S1alc: 'l cxas I ìl lìctir c: "s I 9l 5(i) St¿rtc P l¿ n I ICIIS ^drìll. Mcntal Ilcalth (tlClìS-AMl I) Âpprovcd: Supcrsc'dcs: St¿rtc Plan A(taclulcnt -1, ì i I'agc 15 t(, lhc)' ol' by of ncrid to that be cdmÞl ngs lvher'ô DSI IS s1iì t0 tlt) nol..havc thc ririaìities of'an instì1ution0l scltiÍ9. r¡ccl and connrrinii¡ iinclusion. ^ddilionâll),, rcsitlctrtial dftìe.ând hom¡s liiensulc ol wi).i-Çh pcrfaìn tû.each sclting, ^ll icquircn'ìeÌrl.s, i'riòr enrollrnclt r)l sel bc DSIJS th e IIìPs DSIJS havc tllc dcr nr ând conúùúnil,v iìclusion, DSil lS .reviirvi <,f do iro{luiv'c 1he <¡Lralítics ijf'úr inclusìon. I lôlnc l,iving) llroviders thåt n and a[rtrse, l,iv¡rìgr'. ancl Sr!)portùd I l<lrn ,Ljì1iqg) nrulr cqinþ ¿tre rgsiden[ial oplions constìlner tlie the fbr Living Facililies. I Iomes owted stâte. hôrles ov4re{ì Òr leased by at.r âdditionâl ts. provider greâler th¿n clo3c rd e¡lgagcrìcrìl âclirrii.),, âcccss 10 pro>iìnri1y to lown Ðr 1oih.l 1¡cil fl¡ld !atívùv Þ Yrì1c lhu rhÍrcd ¡rçâs iòr ¡ìrlisirg fi¿iliiy. i¡sj IN Numþer; 16-0001 SrrL)ersedes l-N. 14-0014 Approv¡rl Dale 12-18. 17 Frf'fectivê Datr.r' 07'01 .10 t¡itâtct lcx;lf, I ll);rte lì{ì{l.rvod N4iry 2l) 201tì ll.l,ri,: Al-11ìrr)v, ì l),. r. , r" ltl 1(ì1 j lFtfcr.tivc Datt .luly I "ù1r, lr --,\.,,..,r1 ,r l\r¡¡,,11\. ¡ 1¡. rìrrnr
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Stale: l exas .6 19 I .5(i) Statc Plan I lCllS ^(luìl l\'lcrìt¿ìì I lcalth (llClllS-ANlll) Stalc I)latì Altaclllnc t il.I .i Paoc ló "l-eave tlris ¡rage blanl<." lSt¡rtcr l-cxa:. lD¿tc lìe,..r ue,l [/¿v 2t) ;10 ]G ll.)¿lo Apr)roverj ll( 'r'"rl'nr 1B 201; ll'llÌ:lll1î,r'"Jî :'il{',:'.1.i. ñ^f--.1.,. T\t ,1 ¡ n/ì-f ,r
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S(nte: 'lex:ls lrl llò ct i vc ; .s l9 | 5(¡) Stâte Pl¿r¡r ll(lBS Adult Me nlâl Ilcaltir (llCIlS-r\l\4ll) St¿rtc. I)la:l Allaclrurcll i.l -i l)a¡:,c 29 ¡l¡rtove<l: Sulr,.'rsctìcs t.:lc8c-AMlt . r,' bl0vider dnr'01luìént. Annuâl Sêrvicc I)clivcr'\' WL:llt¡¡tl. /()hctl¡ ¿¡Ltl't IItdI ui)t)Ii¿s): tr Providcr' Scrvicc litlc: Scrvicc [)clìnilion I Sconc). t0 control. that e¡ralrle indivicluals kr ol comnunicate l'ith the lu lly into tìre cclrrrmunìl-r; or fo crrsure çrùirQrnìçrrtûl adaptations. kc9þ,.ci's. rerlindcr !eviccs, and ãicis l'tx daily lii,ing^ sìgns, calcndars- on rhcJll P iíây b¡ nad¡} id ¡ ichiolc thât is not o\yrìod .¡nd is the i¡ tlrdcr lo accônrrodâtc thc idcntilìcd necessiuy tbr the ind ivitlual l0 5(1) necess¡ìry fìdi¡ptiYe âicl cll tvì the il Iì JJld ii þractitioner of l.he hcaling 'Cbu.nseloi, Licensetl i¡ div klua l's need tbr Snccil'r, lirnìts lif aur,) c¡l thc aìnount. duralion. or sco¡e ol lhìs selvicc lot' (<:ltost t'¿,h tltul utDltc'\). l'N Nurnber: 16-0001 lìupersecles 'f Nì 14-0014 Stãie. l-ex¿rs Date lìeceived: fvl.ìv 20. 2010 lf atEr Apprcvûrlr Decenrber'l¿l 2017 E:ffccfÍvo Datc. ,loly 1, 20î(j I Number. l6'0001
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Siate: 'l-ex¿rs E f'lòc1ivc: .s 19 I 5(¡) Stâte l'lan I lCllS Slâtc ltlfln Altâchme r)[ .]. I i ^dult Merìtal llcâlllì (l ICIBS-ANIIl) l'}agc 1ì0 A¡r¡rlove<l: Srrporscdes: ,Mçclicare. óíhèr Ir¡edicLrid be¡rr:ûts^ or 10 acces$ arìy otter antend ent, NI tl lìrvido l'¡'¡re Liccnsc i/t)r,cilìr. Ccltificalion OLlrcl Starrlald !{(ll}S lltovklci, . Agcrni.v-r t hat tieets, t¡c mirìirnum. eligìbilii! ancl stîn¿lifds li)r,. r.¡cBS.AMiì " : ji¡'ovklcr enroiIn9nl. provider agenc._v enl ollc¡.l and wbÍch cnuìo-vs or has corìlmc{s r\ilh ojd provítlers, llelîre ertcrirìg into a ¡rrovicler agreenrent rvith the pÌovitlel agenci, DSfIS lorifìes the ¡rlovidcis' 'compliance wi r th¡"'se quaJìlicatiüns through a.c.redentialiug ploccss Contl cted providc"rs are obligat*l 1o vclil.v basis.thaí these qual iÍr-catbns aidrprdíitlcrs oncl lfióir crÍplo)'ccs rYith rìll ntte la'uvs ând r.vidr 10 IS ICUti provide DSt Îc¡d ìn u¡rf . DsiHS cnlcr lrrcquonc), ol Vcr iiìcation ¡S¡tt't il.i: ) [)rovi(lcl l),pr (Spct;i/y't. l:ir1it) l{esPonsiLrle lbr Veril icâlion (Speúh.'): llCBSjtrovirler' .. r af:Qnçy lharr¡r¡eéts thc ¡riilimurii . , clisibility arid: . r,, stand¡l'<ls 1ìli ' lt{tBS:,-{M} I . ,. " irov i<iài ônr¡iÌìnr erií,' irsHs .'..': .Ailnunl Scr-vicc Delivcry Methotl. ( (' h ¿(: k.xtch I h a l d t) t.l ¡ c \ ). tl Paltici iÏected l)r'oviclcl m¿uragcd fì¿ce¡vcd: Mery 20. ?010 Apprcvtrd. Dece ber 1ô. i.101 / TN Nu n1lre. 16-0001 Ap¡rroval Däte. 12,18-17 Effectivó Date 07-01 16 Supersedes'lN: 14-0014 DâiÈì .JLly 1. 201û itiai Nl rÌïlrer: I6-000-l
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SLâlc: l cx¿rs trflèct ive; ¡rprovccl: -s I9 I 5(i) State Plan I lClllS Adult Mcnlâl I lcalth (llCUS-ÂNll'l) Stâtc Pllln A tt¿clì trù t i, I --ì I'a¡rc 3 5 StI¡erscclcs: Sr¡r'r'icc¡ li1ìc; Scrvicc I)olìnilion (ScoDc li t¡i $erv ¿trnd ired r.¡ndcr,,l2 ,fCS0Ul'Oes- ¿lS t.n û ¿urspôr'lâti{)r1 requ Cl'F.R. $ 4i 1..51ì ¿titl. ,applicablc)r a d r'vÌlì 440.1 70(rì) {it T\ìansporlal plan thurìly, 'lltis s,9lvrcc uncler tte St¿rlc Pla¡ nr eclic¿rl '.[lanS¡:Òrcado.n ielated to goals ìclc'Dlif ie(l on the ?ùl e reqU iLed ahcl fes snd procecl ures ling anrl aù not.duplicativc rìr inchsivc ol' rg r[r] tilxlsporialí0ù benelils , . S),siem èdils clicnf rccover.r manag;cr ancl thc "s atear l -Ihc s[âtQ when the lL a]ls¡rorlatio .I,;iving.or lìnì¡rlnyrnerìt Services. Services sh¡ill be hiljed il ¿i¿ôict¿ncervith t rs(i) I OCeSSãq¡ nojl-emer'ge.f rcy ân pursuant 1o the lìPSIJ f' slale p1 lhc il lc I rhe drìr'¿rt ol'this scrvice f0r Câtùi¿orically rec(ly (sn.'cilì, l¡atil.t ): I 'I'hele ii a.linìii ìl Det':'ieâr.1-oiÌ.ih is sc NA Ccrril'lcâtioo 01hcr St¡nclard Irrovidcr 'l')'pe l-icensc l,Þ¡r¿ fj.J. llocelved: 1V¿y 20. 1ì{l1ô Approved: l)ecc.nlbcr lf] :lO'l i' f ilxas Da{eì .July 1. 20'lfi ittal Nurlirr] r: 10 000'l f\l NLln]ber 16-0001 l;upersedes -IN: 14-00f 4 Approval Dale. 12-1 B-17 EffeOtive D¿:ìtL.r 07 -AI 16
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State:Texãs Effect¡ve 51915(i) State Pla n HCBS Adult Mental Health (HCBS-AMH) Approved: State Pla n Attachrnent 3,l-i Page 48 Supersedes: intlrÀiviir to thc.n]ûxillluln cttùnt Ðos$¡blc'and cûch i nrust he Thù $¡ll d(ìcu¡rùnt iìÌì,\' plmÌr¡d irlterlcnli() ulilcJr q<¡ulcl l¡ cc¡rscnt ol'thc incliyirjuirl tq tlE vention yill c8rìsc rþ.fu1rn tô rh{} indiridu¿|. 'l he ll he çncou¡¿gecl is rrol c thù ìhat ll)È l Íhe assessnjùil per f ìl mc,rl tn ,,pun u qL¡¿lt'tcrl): ¿nd ¡Û rrll. hiéor1¿ìl ôu-siLc lnaal.1.Ìl-:t] sqltirìg rrrd is liJl nlcmlrc¡t iÌs b,v I hcì itcts tlu( ¡rud âi(ì. (il¡alì lied r¡Ji-r id r¡a l's txl I l 1r,''ì,\ri,.1ìfv,r\rl\ /rDr, ili liniittI 'f c xáì,q TN Numher: 10-0001 Supersedes 'fN: 14{014 Approval D ate. 1 ?--1 8-17 F.:ffective Dale; 07'01..1 6 lìecerved. N4ay 20 2016 Approvcdr Docenri:c:r 18 201/ Llale..l[]y 1.2016
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Sta(c: I cx¿ì.s ssl9l5(i) Statc l)lan I ICIIS AdLrll lr4c:ìtal lleal(h (l I(lUS-AMl I) ApProva I P¿1ç 12-18-17 Eff ect i ve Date : _QlQ1_![ St¿ìlc l)ì¿ììr ^ttâclìnlcD1 .j,I l I'agc,53 TN, 16-0001 :'fexâs [ì€]ceived: May '10 2 010 Approvercl: Deconrlrùr 16, 2t117 D¿rtër .l uly 1, 2 016 nslll¡tlal Numl:,er: '] ti-0001 irpijil â qüsr{ffly îsscssnìcr'rt .¿Jü¿unreriied ì¡ìilìe. tlìP ùiil sclvi¿ìéi hà¡,i' 0f living unils will ¡tcccss. ¡Iltd rrrrdcl R) a nror'lilìcarìori. of peì ion-cenlcred sûppoÍs usçd Lreen triecl intcl\,elìti()rls at)d htlt did rìot wo[l(; a ¡lear dùscliipti0n ól tlìe collcction a ntl rcrvicu ol reviews to deterrrine ifthe irr lriimcd ùssur-âncc [lìât ìrìlctventio]ìs and Setlings klqjlì1âte choice rigardiiìg scrvi¡es íÌnd iupporls írnd u'ho lÈ right to assuìne r;sk, tenrÞeled only by the furnishcd i]ì ¡ rvay lh¿t foslÒrij lhc indcpcn(lcncc of'e¿ch be ilxlividìral-dlivcn to drc nâxirilunl (\\tcul IRP will docLlnrcnt ¿rnv ¡rlanncd inlcrvellion u'hjch and c0u oll the the specilic i.lìe ..iltéir,è¡rtióiì DSI,IS rvill Ìev ieqr:iliè enstìre th¿t it. i.s conununittib¿sed^ iìrcftrsive. arìd bicnnii:rl leviervs of ¡csidetlial servic'es in ¡ll selii!gs. DSHS ço¡dur:ts bir:nilial on-síte of (ll instituti0n0l sqlting. Dìe0{ .iir seLvice.is HOB seÍjng süggests chalge reeded, i¡lr tti dctcr'¡úinc the and as b5, dre cr"ulcnt of' driìl constilulè arrd cxploitaLkrn ate qualìfìed ro tfe ind ivitlual's Âridirit¡ral ncccls-Lrasccl clilcria lìrr leccivin!11hc scrvicc, il t¡pplicablc lvrrt¡7j,t. Spccil\ linr its (il'nn-v') on lhc anrouirl. cluration. or scopc ol l.his ser vicc [<¡t (t;ho.tt c,t(:lt lht.tl dppli(.s ). ( r¡rc..:,rliuullr rLcLlr ry',, ili /lrrrlr.rt Su persedes rlt : jj-{11--
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1¡ 16'0001 rs l9I 5(i) Statc Plan IICIIS Atl0lt lt4crlal llcallh (l ICIIS-t\Ml l) Approva 1¡¿1¿.. 12-L8-11 51a1c l)lar ,A.t(âolìrlrcnt -i.I I I'age 57 Daio: Jirly -l , 2010 S tatc: 'l cx¿rs :l-exas Recejvûd: [,/lay 20 20'] 0 Approvecl: DßceÌrbÊr 18. 2017 .t\ been modilÌiarion: Jìome and prior lo an.v çosfs luol billab qfnrcel.ing [he need Çill) in theil õvìrot fàrn ilr, rÈsìdence. Whc¡r rneuilTer.s; it is desìgned to suplloÍ dreir. own honlê$ recei\;e $upp(ìrled íÌrìcl ate lileverìt lhe Ûì in their ftrdependcnt lesidence, by an inrJividLraìízcd asscssrÌrrlnl lhc irdì úiciurl's IRP ílre dclgrnincd ¡ecessar.y. basctl upotr n l)StlS will revierv ihe autholized delível selvicre.i sen icé, âre hrch¡ditl,h the iridi'ect Suiioltcd selvlces are sfuto llCUS ond lvi.ll tevtews Pèr'bilii. qrìalifiecl.io elìslrfe 'I'he sfäte arrtl nrelhorls to âsÍeèderl. 1o cnsure scrvice ploVi.deis nre .a¡¡l lederol larví arcl r'egulatirxrs): ancl t0 ¡\ddilion¡l ¡rccds-llasc'rl crilcrir lbr reccivillg, (he selvice, it zrpplicable ¡yLr<:ì/¡1; S¡ccì1j lirrrits (if an-v) c¡tt fhc arnounl, drr[iìtion, or sco¡rc ol'this sctvicc 1br lc,¿,.r'rr.nth t/ut ttlt¡tlia:). E, Oatcgcl ical 11 ìeed.\ (sp e¿ ¡li.' li n i Lt.). Su persedes TN 1"4-0014 Effectìve Date: _lq7-01-16 nÊnlift¡ìl l\lr rûiìÈ.r Jlì-.{)ll0 i
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Sla1c: l-cx¿rs lìflòctn'c: ¡s I9 I 5(i) Statc Plar I lclllS ,Aduir Menlal Ilea.llh (l-lCì IìS-ÂN4l l) ¡r¡rloved; Srrpcrsccìcsr St¿rtc I)lnn Atlachure'rl i.I i l)a¡lc ó5 Sorvicc Iitlc: lr.Nirrsìno ':rr. ScÌvice Dcfiniti(nì (Scope). cÈs aJc, state 1t RrN. (rn' ..0r sldte la\v.!g proccdules rnonitoling o1' health c,are .i1rìndíìrdi of prol'cssiolal practice age 2l and ovel.r. All r¡reclical ly necessatl" rtutsing sclviccs arlnr laíki. lhis (inc'lu{irrg kain ing. the scope o1'rl:ese Addilional ¡eeds-b¡sccl clitclia 1ìrl lecci {hc sc lc rluì ulion. 0l' of'this sc¡r,icc fbr. N ulsllg al'ter' 0r l)of burne healtli benef its. or olhel fhi|d Mcclical I)ro\i(icr'l'."-p(' l..icensc l,t)c. i/ì.rl Ccrtilicalion l)rovidcr lificâ t ¡()rs Othcr Sland¿rrd I-iccnsLrrc N HCBS with colltfâc1s sefiice l Ust l'or dc'livery cornply of trursing ihis ft$ guch u¡ eIrìerts r9q Act Niirse Prootice tssk l)r'ovidcr'l ¡1c (,\pt:ci/j'): f:)rtily llcspo¡ì.iible lìr' Velilicatìon t Snccil\'); l"r cc¡Lrcrr c¡' o l' Vcr.Ìfi cation i\p&i/r): llSllS ':r I 'rr',': , ,,,:r:r'r' .:,.,t:r . ,:::t.:.:.. I:,ìì-ì1,I : . .. ì i ì::ì. i:::4, . - . . :. ",..ìì ' :rr:ì:..:.tt . : iìu,,ì.ì:.r':.:r.:rì :ì .ììì . :. r:ìì: ì:::ì.r .. : ìr::rr:r:.:i.::,r .::] : An¡rr¡l liliï r mñ' ltiro,lr- ,\ F,rovar LlJt"'' ? 18¡7@ lStrp-^rsedes IN. 14 ()014 I exaSi r?rnsrniltâl l! unìbclr 16-0001 D¿rie f:ìeceivcd: Nf¿)y 20 2016 Ilate Approve(Ji Deconrbr:r 18 201 / fffeclive D;]iÉ: iuly l , 20 16
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S1iìtù; l ex¿ìs llllèct ivc: \s I 9l 5(i) St.ôte I'liul I lClllS Adult lr4cltal llcâlrh (l IClllS-AMl l) Ap¡rroi'c'd: Supclscrlcs: St¿ìtc I)laD Altaclrmcrl i.I i l)agc 6(r IC I)cl M Ë Plor.iclcr ma State. l'exas Däte Rrjcìeived: I,ltay 20. ?.014 Dale Approve d: Deftrmhêr '111. 20'17 L:ffectivú Dãi,¡r July i iì01{ì 'Tì ¿r nsrniltâl NLrn.ìl)nr J 6^0001 TN Numbrìr: 1S.0001 Supersedes TN: 14 -0014. AÞpiovaì Dale. 1?- 18-17 Ëlfeciive l.li:rte: 07 0'1 16
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S tr(c: -l'cxâs l.:)llìctir.e; Ap¡rlovetl: -s ì 9l 5(i) Slâ.te l)lar I l(lllS Adulr t\4cnlal t.lcâlih (l ICIBS-AN4ll) S1¿r1c Pl¿ùr AIt¿rch rrcìrt i.I-i l'agc ó7 St¡tre lscrlcs: Scrvicc Spccilicati o\s (S¡tt,c:i/i, ct tct |icc l¡tlc /tù' lhe Il('ßS litted in ,lttLtc:hnt:nt 4. 19-1) th¿t lh( Stul! plun.\ lo lJse Sclr,icc I illc Servicc iealizirig fheir clesilei Ìqc¿rvcr'_v liorìls. ll(jtls reco\aer-} goals. Services rvillbe $.uÇh ôs peqr suÞlloll as allplopï¡ate to A ll. lìred içaliy. tleccssary Sl)D serviccs i'or wllo h¿ve o1' tÌ'Ì iclcni ificd hc goals ile wh arìclrcssing fi ea1nlent wiìl SIJT) ¡r1an the nodate antl Ì¡clchc.ss cvìdeÌ'iie-itfbrrnecl tJ e¿tnìent ol othel cornrnunity-trased IICBS StlD lrerreliI Lrnless nòedi, and recover-"v goals as io¡.irg ljmjtaibns, ol a nrcntal f hrr ì l.v- co unsel in¡¡; .$i:rvices be Servicc-i ¡re de$igried to eihàùst her .5(Ð only parlicipalion ò1h€!,st¿ile relâi.5e. liervicçs àre 'T'his rl9l ¿hilih'cn thc icable Add il ion¡l nccds+asccl cli¡c|ia fbr' SD,rcil\ lintils {i1'ûr'rvion lhc anroLflrf. (luriì1¡rnl. or scoDe ol this servicc l<\' (ch¡sc ,tt.t¿:lt thdt t"rDÞli(.!i): Oirtcqoricaìlt ¡tcctlt' (s pecí /l' I i n i ts ) : tr SLID seÌvices- 1ì01 ôs l'¡ or, itle l 0 u nlilicl tio¡s (I; or ettt:h h'l¡t r¡/ ttn¡, idc:t . (:ot)t: ft )ts u.t nÌ¿lctl) L.icensc ßpcci.[1. Ccrtilìcatiol OLIìcr Staììdald Pì 0vidcr 'l \rpe th¡oúgh û credentialing plocess. conlracts witlr SIJD licensecl anil,/or fo provide setvÌces licensule 1¡1 prcvider gre9ment enteft verifìcs I)SI IS lhe irh thesc ûre to obligated velif¡. thrlt these qua lilications ol-Statc nlust tlq. (leci)Ìis ,by DSLIS; SLJI) N Nunrber: 16-000'1 ;upersedes IN: l4-00I4 Approval Datêr '12- 1 8-17 [ffóctìvÉ Dale: 07'0]-l(j Dáte lìÉoeived May 20 201ô Dale llpprîvôd D(:,roenìbËjr 1¿ì 2017 Ëllectrve пrte: ,JLrly 1. 20 1ô
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S1¿ì1e : l cx¿rs I:rllèc1ivc: .s l9l5(i) StâLc Phl ll(ìllS St¿rte l)lan Altaclrnrcrt i,I i Adlrll l\4enral I leâlth (l lL:us-i\ N4l l) f'agc ótì Ap¡rror,c'd: Sttpctscdcs: DSI IS ílrìrì u a I to corìtirlno Hli e..oter Vclil ic¿llion ol Pro\'¡dcr Provir.lcr"lypc ('SPtt:ì1i,.1. []n{it}' Iìesponsiblc lbr VcriÍication ìrlct¡ucnc¡' o1' Vcri licar ion (Speci/.¡'1: n Purlic t.-ciirectcd P¡ov ir.Jc¡' I Dakr: 12-'l tl-17 : .fexas Rêrxìived: ft4ay iì0 2û 1 6 Approved: llcrcenìber 18, 2017 Date: .July 1. 20'16 nsmitt;rl Nuiîberi -l 0-000'l persôdes IN: 14-0014
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S1nlc: l'cx¿rs òs l9 I 5( ¡) Statc Plan I JClllS ,A(lu11 Mental I Iealth (llCllS-AMll) A pploYetl State Plan ^tiâchrncnt i. | -i I'agc 7() I Ìfìecl.ivc: Supclscrlcs N sdr lleceived i\4ay 20. 2010 Approved Deccrìber 'l[i, ?017 o xa!ì Ilãte : .luly 1.20.16 Nuffber: I6.$001 u 12-18,17 Da te: SLrpersedes TN. 14-0014
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Stâlc: 'l c-\as Effective: .s I 1) I 5(¡) Statr- Pl¿n I ICIIS Aduil I\4cnlai I lcalth (ll(l13S-AMII) Applovccl: Slatc Itlâll ^ttaclll]lcrt ì.1 -l I'a1¡c Íì2 Su¡rcrsctlcs: SJ strur lll¡Dlovcr¡ìcnt: l\'1c11ìo(ls fi)r Àn¿ll riûr l)¿ìt¡ rllr(l Iì iorilizini¿ \ccil IÌ)r S\ stclù lnìl)rorcìÌl!'lrt l{olcs entl I{csoonsihililics l:rcquonc) i\lcthoLl lì)r lr!irluiili rg l:lli'cli\ crìoss ol' S\.slcìn (ih¡ n,lùs dìttrì l)$H¡ì willì cillècl, collátc- rc\-ig\Í, .:. and posì,1 [l1fjç ltrjll,j'ivìerv tlte dîlti. tn¡ Ir¿vò.jiñ¿ìl ¿ìiectiirii.over r.' r''::: corrçül r\'ù ¿lcf t(ltì plillì5. ' .r' . .. ì ":: l:, :i . . '..'l'l' '. . :...a. :,. .:l:,.,'ì.ì,: ,, rt .,i:.']l ,l.lpd41Èú rc.nctiièd n1{)t)1hJ)'.0¡{J -. quùr'lill\,'r,' :, Sc1 Êcìrlì)nrtàlùc bcûchììlarli :" .ì.l.cr,icrv of sclvicc lrcnds llc!r(rr nrogr,rr)r irììl)lL'nrtiìl.rl ion 'li¿ìck rìd f L'nd syslùìTr pÇrlofl)r¿l¡cù An¡Ì)ic thr'. {liscovcr'-\'r syrìthltsi?.0 lhL! dr t{rl :XillS. vilh llllS(', rvìll nrafiç corcùlive actiolr plans T"rgâr(liIg iluirlity . ìrn¡rllr crncnt 1Ql). I)SIlti Niil |crìerr (ll recorrnrcuiialkrns, quuiir ly and hì.rjl(l rlmr lhosc .' , .ìlnpro\,c'!ì1cnls l.hrou!Ì corìlinuolrs qu¿ìlill, ìntpror crrtcrtt. . ' :.Asscss s)ìsaom cirârÌfles lriìct¡s or .iopor'tirr¡l r'oquirc)rÌcûls rur(l rô.lirìing rri)orl:ì':' l.)SHS \y¡ll. arlllcllq.a[â lvzc- âud :.]..-: retlorr. Ill {SC' liròiiidct o\ crsiglìt âiid cliq:ctk¡r,. .:'ì.., ..:. , ,.,.'. i.,.. t, i: : .:.:.. :: . r '..r..,. .ì:. Qì.rirlcrly rncotilus . . \4orìilorirrg .$otrflcl .1n(l IICBS corr¡rliuìrcc lìr scrvii:c delilcr-r r. llrvierv ol clinical a$stJrJr)rarìt clicú[ . oltc(ìtncfìtL1ìsuÍ)t Or)ritc rÈ!jiê!\s . Do¡rìììe¡fátio¡r . ,tle.ricrv . .' .' . .(hsiic. i'lql:yie\\ ,.: t': ir,v id llov tsst¡es {tÎ¡ì ¡\ rì trù i!l l], .]fl,r:, .]' :, - r. . .f. i:r ..':'..ì .l:li:, lì.cvictr oi'clinical opclatioos (ritì1ìzliion tnirnirlcnìcrtl. (luiìlil\' nr.rfi ¿l:rctlì(rì1. cirr( nlánirgctucrt, cor¡pl ja0cq $i1 lì 1.1(lll sçtlìl)gs rei)ltilclÌrenl.s) ¡ C{)urplilìûcÈ ì,rsuc$ \!i¡l rçqrirc 1¡,} .: sr¡liiTìissìo!ì¡f¡lcorrcctiv!'¡cljiì¡lplül ì.' Iì$lt,! loÌ {pirio\,¿ìl ¡nd oÍgoing monil,rlinA. (l¡r¡cctivc (CAP) ircli()ìr plâtr¡ ¡hlll ¿lic a(:lroll ol'ihe rùich ,^rc¿Ls ¿ls Frr tkri ¡lxrlysis cjl'pcrlìrllarlo.' datr ( )Ilsi1c rc\ icw li'ìdirì!ij Ltl U.rì:r¡rìr flLì0- compl ianci,l.ìrllorv-r.rp l-exils Roceived: l\4ay ?0, 20.16 Approvecl. l-)Õ0ëmll$f 18, 2017 Ll,îtÊ July 1. 2ù 1ô Fñl,r"i,r l{r{C¡l @--_-i:Îc, i\", ilËõ-õiî{-l ìS'rnt,rs,,rler fN 14 r)0 l4 | .-'i¡irl âl Nll rfthñr"1A..nnfì1
(spa)(tx-17-0024)(approval-document)Texas Medicaid SPA TX-17-0024: Approval Document (approved December 13, 2017, effective August 1, 2017)#
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Table of Contents State/Territory Name: TX State Plan Amendment (SPA) #:17-0024 1) Approval Letter 2) CMS 179 Form 3) SPA Pages
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1/11/2018 TX - Submission Package - TX2017MS0004O - (TX-17-0024) - Eligibility https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0cLS686GhhLQgRf5E7z-wNvEPIQRVzvbAgHdSwtu_ygqyMOESN3NPjfrnNOf-y8z2zcfsTLRYBxWG1nzc8TFRJy/vi… 1/14 CMS-10434 OMB 0938-1188 Approval Notice DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-14-26 Baltimore, Maryland 21244-1850 Date: 12/13/2017 Head of Agency: Enrique Marquez Title/Dept : Deputy Executive Commissioner Address 1: 4900 N. Lamar Address 2: City : Austin State: TX Zip: 78751 MACPro Package ID: TX2017MS0004O SPA ID: TX-17-0024 Subject Approval NotiÒcation Dear Enrique Marquez This is an informal communication that will be followed with an oÕcial communication to the State's Medicaid Director. The Centers for Medicare and Medicaid Services (CMS) is pleased to inform you that we are recommending approval for your request for Transmittal Number (TN) 17-0024. Reviewable Unit E×ective Date MAGI-Based Methodologies 8/1/2017 Financial Eligibility Requirements for Non-MAGI Groups 8/1/2017 Mandatory Eligibility Groups 8/1/2017 Parents and Other Caretaker Relatives 8/1/2017 There is no Federal Medical Assistance Percentage (FMAP) associated with this SPA. Sincerely, Billy Farrell ARA
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1/11/2018 TX - Submission Package - TX2017MS0004O - (TX-17-0024) - Eligibility https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0cLS686GhhLQgRf5E7z-wNvEPIQRVzvbAgHdSwtu_ygqyMOESN3NPjfrnNOf-y8z2zcfsTLRYBxWG1nzc8TFRJy/vi… 2/14 Approval Documentation Name Date Created Ty pe 6.A.1 TX 17-0024 ApprovalLet_FJB bdb 12/13/2017 4:05 PM EST Package Information Package ID TX2017MS0004O Program Name N/A SPA ID TX-17-0024 Version Number 2 Submitted By Berengere Dutra Package Disposition Priority Code P2 Submission Type OÕcial State TX Region Dallas, TX Package Status Closed-Approved Submission Date 9/29/2017 Approval Date 12/13/2017 8:45 AM EST Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | TX2017MS0004O | TX-17-0024 Package Header Package ID TX2017MS0004O Submission Type OÕcial Approval Date 12/13/2017 Superseded SPA ID N/A SPA ID TX-17-0024 Initial Submission Date 9/29/2017 E×ective Date N/A State Information State/Territory Name: Texas Medicaid Agency Name: Texas Health and Human Services Commission Submission Component Submission Type Allow this oÕcial package to be viewable by other states? Not Started In Progress Complete State Plan Amendment Medicaid CHIP OÕcial Submission Package Draft Submission Package Yes No
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1/11/2018 TX - Submission Package - TX2017MS0004O - (TX-17-0024) - Eligibility https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0cLS686GhhLQgRf5E7z-wNvEPIQRVzvbAgHdSwtu_ygqyMOESN3NPjfrnNOf-y8z2zcfsTLRYBxWG1nzc8TFRJy/vi… 3/14 Key Contacts Name Title Phone Number Email Address Dutra, Beren State Plan Program Specialist (512)428-1932 Beren.Dutra@hhsc.state.tx.us Ates, Doneshia State Plan Policy Advisor (512)428-1963 Doneshia.Ates@hhsc.state.tx.us SPA ID and E×ective Date SPA ID TX-17-0024 Reviewable Unit Proposed E×ective Date MAGI-Based Methodologies 8/1/2017 Financial Eligibility Requirements for Non-MAGI Groups 8/1/2017 Mandatory Eligibility Groups 8/1/2017 Parents and Other Caretaker Relatives 8/1/2017 Executive Summary Summary Description Including Goals and Objectives The proposed amendment corrects the Medicaid State Plan to reÓect the state option to terminate Medicaid coverage for certain individuals who fail to meet the work requirements under Title IV-A of the Social Security Act. SpeciÒcally, §1931(b)(3)(A) of the Act gives states the option to terminate medical assistance (except for certain pregnant women and children) for individuals who fail to meet the Temporary Assistance for Needy Families work requirements. This option was removed from the Medicaid State Plan in error. The Texas Health and Human Services Commission has continued to apply this policy option. Feedback: In July 2016, Texas discovered through implementing CMS' direction in deleting pages of the Medicaid state plan superseded by the MAGI SPAs, that the TANF work requirement was inadvertently deleted. SpeciÒcally, Supplement 14 to Attachment 2.6-A contained an option to terminate medical assistance for individuals who failed to meet TANF work requirements. SPA 14-0002 M1 removed this page but none of the superseded pages contain this optional provision. The Medicaid denial for failure to comply with TANF work requirements is stated in 42 USC 1396u-1(b)(3) and Texas HR Code 31.0032(c). After reviewing Texas State Plan Amendment 14-002 that Texas identiÒed, as well as 16-0024, CMS saw where Attachment 2.6-A, Supplement 14, pages 1-2 were deleted. To add this option back to the state plan, Texas needs to submit PDF S25 in MMDL and upload an attachment that includes the relevant language from Supplement 14, Attachment 2.6 page 2 that reads, “The agency terminates medical assistance (except for certain pregnant women and children) for individuals who fail to meet TANF work requirements.” Dependency Description Description of any dependencies between this submission package and any other submission package undergoing review Disaster-Related Submission This submission is related to a disaster Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact Yes No
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1/11/2018 TX - Submission Package - TX2017MS0004O - (TX-17-0024) - Eligibility https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0cLS686GhhLQgRf5E7z-wNvEPIQRVzvbAgHdSwtu_ygqyMOESN3NPjfrnNOf-y8z2zcfsTLRYBxWG1nzc8TFRJy/vi… 4/14 Federal Fiscal Year Amount First 2017 $0 Second 2018 $0 Federal Statute / Regulation Citation §1931(b)(3)(A) Governor's OÕce Review Describe Sent to Governor’s OÕce this date. Comments, if any, will be forwarded upon receipt. Authorized Submitter The following information will be provided by the system once the package is submitted to CMS. Name of Authorized Submitter Berengere Dutra Phone number 5129234163 Email address beren.dutra@hhsc.state.tx.us Authorized Submitter's Signature Berengere Dutra Submission - Public Comment MEDICAID | Medicaid State Plan | Eligibility | TX2017MS0004O | TX-17-0024 Package Header Package ID TX2017MS0004O Submission Type OÕcial Approval Date 12/13/2017 Superseded SPA ID N/A SPA ID TX-17-0024 Initial Submission Date 9/29/2017 E×ective Date N/A Indicate whether public comment was solicited with respect to this submission. Indicate how public comment was solicited: No comment Comments received No response within 45 days Other I hereby certify that I am authorized to submit this package on behalf of the Medicaid Agency. Not Started In Progress Complete Public notice was not federally required and comment was not solicited Public notice was not federally required, but comment was solicited Public notice was federally required and comment was solicited
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1/11/2018 TX - Submission Package - TX2017MS0004O - (TX-17-0024) - Eligibility https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0cLS686GhhLQgRf5E7z-wNvEPIQRVzvbAgHdSwtu_ygqyMOESN3NPjfrnNOf-y8z2zcfsTLRYBxWG1nzc8TFRJy/vi… 5/14 Name of method: Date: Description: Public Notice published in the Texas Register 7/21/2017 The Texas Health and Human Services Commission announced its intent to submit transmittal number 17-0024 to the Texas State Plan for Medical Assistance, under Title XIX of the Social Security Act. Upload copies of public notices and other documents used Name Date Created Ty pe 20170721 SPA 17-0024 PNI 9/28/2017 12:44 PM EDT Upload with this application a written summary of public comments received (optional) Name Date Created Ty pe No items available Indicate the key issues raised during the public comment period (optional) Newspaper Announcement Publication in state's administrative record, in accordance with the administrative procedures requirements Email to Electronic Mailing List or Similar Mechanism Website Notice Public Hearing or Meeting Other method Access Quality Cost Payment methodology Eligibility BeneÒts Service delivery Other issue
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1/11/2018 TX - Submission Package - TX2017MS0004O - (TX-17-0024) - Eligibility https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0cLS686GhhLQgRf5E7z-wNvEPIQRVzvbAgHdSwtu_ygqyMOESN3NPjfrnNOf-y8z2zcfsTLRYBxWG1nzc8TFRJy/vi… 6/14 Submission - Tribal Input MEDICAID | Medicaid State Plan | Eligibility | TX2017MS0004O | TX-17-0024 Package Header Package ID TX2017MS0004O Submission Type OÕcial Approval Date 12/13/2017 Superseded SPA ID N/A SPA ID TX-17-0024 Initial Submission Date 9/29/2017 E×ective Date N/A One or more Indian health programs or Urban Indian Organizations furnish health care services in this state This state plan amendment is likely to have a direct e×ect on Indians, Indian health programs or Urban Indian Organizations Complete the following information regarding any solicitation of advice and/or tribal consultation conducted with respect to this submission: Solicitation of advice and/or Tribal consultation was conducted in the following manner: Date of solicitation/consultation: Method of solicitation/consultation: 7/7/2017 Letters were submitted via email. States are not required to consult with Indian tribal governments, but if such consultation was conducted voluntarily, provide information about such consultation below: Date of consultation: Method of consultation: 7/7/2017 Letters were submitted via email. The state must upload copies of documents that support the solicitation of advice in accordance with statutory requirements, including any notices sent to Indian Health Programs and/or Urban Indian Organizations, as well as attendee lists if face-to-face meetings were held. Also upload documents with comments received from Indian Health Programs or Urban Indian Organizations and the state's responses to any issues raised. Alternatively indicate the key issues and summarize any comments received below and describe how the state incorporated them into the design of its program. Name Date Created Ty pe Not Started In Progress Complete Yes No Yes No The state has solicited advice from Indian Health Programs and/or Urban Indian Organizations, as required by section 1902(a)(73) of the Social Security Act, prior to submission of this SPA All Indian Health Programs All Urban Indian Organizations All Indian Tribes
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1/11/2018 TX - Submission Package - TX2017MS0004O - (TX-17-0024) - Eligibility https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0cLS686GhhLQgRf5E7z-wNvEPIQRVzvbAgHdSwtu_ygqyMOESN3NPjfrnNOf-y8z2zcfsTLRYBxWG1nzc8TFRJy/vi… 7/14 Name Date Created Ty pe 20170707 SPA 17-0024 TANF Work Requirement Tribal Notices - Ms. Sylestine 9/28/2017 12:53 PM EDT 20170707 SPA 17-0024 TANF Work Requirement Tribal Notice - Ms. Battise 9/28/2017 12:54 PM EDT 20170707 SPA 17-0024 TANF Work Requirement Tribal Notice - Mr. Gonzalez 9/28/2017 12:55 PM EDT 20170707 SPA 17-0024 TANF Work Requirement Tribal Notice - Ms. Hernandez 9/28/2017 12:55 PM EDT 20170707 SPA 17-0024 TANF Work Requirement Tribal Notice - Ms. Young 9/28/2017 12:56 PM EDT 20170707 SPA 17-0024 TANF Work Requirement Tribal Notice - Ms. Trentin 9/28/2017 12:56 PM EDT 20170707 SPA 17-0024 TANF Work Requirement Tribal Notice - Mr. Hisa 9/28/2017 1:01 PM EDT 20170707 SPA 17-0024 TANF Work Requirement Tribal Notice - Mr. Lopez 9/28/2017 1:01 PM EDT 1 – 8 of 8 Indicate the key issues raised (optional) Medicaid State Plan Eligibility MAGI Based Methodologies MEDICAID | Medicaid State Plan | Eligibility | TX2017MS0004O | TX-17-0024 Package Header Package ID TX2017MS0004O SPA ID TX-17-0024 Access Quality Cost Payment methodology Eligibility BeneÒts Service delivery Other issue Not Started In Progress Complete
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1/11/2018 TX - Submission Package - TX2017MS0004O - (TX-17-0024) - Eligibility https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0cLS686GhhLQgRf5E7z-wNvEPIQRVzvbAgHdSwtu_ygqyMOESN3NPjfrnNOf-y8z2zcfsTLRYBxWG1nzc8TFRJy/vi… 8/14 Submission Type OÕcial Approval Date 12/13/2017 Superseded SPA ID TX-16-0024 User-Entered Initial Submission Date 9/29/2017 E×ective Date 8/1/2017 The state will apply ModiÒed Adjusted Gross Income (MAGI)-based methodologies as described below, and consistent with 42 CFR 435.603. A. Household Composition 1. In determining family size for the eligibility determination of a pregnant woman, she is counted as herself plus each of the children she is expected to deliver. 2. In determining family size for the eligibility determination of the other individuals in a household that includes a pregnant woman: 3. In establishing household composition under the rules for non-Òlers set forth at 42 CFR 435.603(f)(3), the state elects the following age for children: B. Household Income Financial eligibility is determined consistent with the following provisions: 1. When determining eligibility for new applicants, Ònancial eligibility is based on current monthly income and family size. 2. When determining eligibility for current beneÒciaries, Ònancial eligibility is based on: 3. In determining current monthly or projected annual household income, the state considers reasonably predictable changes in income: 4. MAGI-based income is calculated using the Ònancial methodologies deÒned in section 36B(d)(2)(B) of the Internal Revenue Code, except as described at 42 CFR 435.603(e), and without regard to whether an individual expects to Òle taxes. 5. Except as provided at 42 CFR 435.603(d)(2) through (d)(4), household income is the sum of the MAGI-based income of every individual included in the individual's household. 6. In determining the eligibility of an individual using MAGI-based income, the state must subtract an amount equivalent to 5 percentage points of the federal poverty level for the applicable family size only to determine the eligibility of an individual for medical assistance under the eligibility group with the highest income standard using MAGI-based methodologies in the applicable Title of the Act, but not to determine eligibility for a particular eligibility group. 7. Household income includes actually available cash support, exceeding nominal amounts, provided by the person claiming an individual described at §435.603(f)(2)(i) as a tax dependent. The state uses a speciÒc nominal amount and frequency. a. The amount of the nominal amount is: $50.00 b. Frequency of the nominal amount: a. The pregnant woman is counted just as herself. b. The pregnant woman is counted as herself, plus one. c. The pregnant woman is counted as herself, plus the number of children she is expected to deliver. a. Age 19 b. Age 19, or in the case of full-time students, age 21 a. Current monthly household income and family size b. Projected annual household income and family size for the remaining months of the current calendar year. Yes No Yes No Yes No i. Weekly ii. Bi-weekly iii. Monthly
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1/11/2018 TX - Submission Package - TX2017MS0004O - (TX-17-0024) - Eligibility https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0cLS686GhhLQgRf5E7z-wNvEPIQRVzvbAgHdSwtu_ygqyMOESN3NPjfrnNOf-y8z2zcfsTLRYBxWG1nzc8TFRJy/vi… 9/14 c. Explanation: optional C. Resource Test There is no resource test applied to eligibility groups that use MAGI-based methodologies. D. Additional Information (optional) Medicaid State Plan Eligibility Financial Eligibility Requirements for Non-MAGI Groups MEDICAID | Medicaid State Plan | Eligibility | TX2017MS0004O | TX-17-0024 Package Header Package ID TX2017MS0004O Submission Type OÕcial Approval Date 12/13/2017 Superseded SPA ID N/A SPA ID TX-17-0024 Initial Submission Date 9/29/2017 E×ective Date 8/1/2017 The state applies the following Ònancial methodologies for all eligibility groups whose eligibility is not based on modiÒed adjusted gross income (MAGI) rules (described in 42 C.F.R. §435.603): A. Financial Eligibility Methodologies B. Eligibility Determinations of Aged, Blind and Disabled Individuals Eligibility is determined for aged, blind and disabled individuals based on one of the following: The state has an agreement under section 1634 of the Social Security Act for the Social Security Administration to determine Medicaid eligibility of SSI beneÒciaries. For all other individuals who seek Medicaid eligibility on the basis of being aged, blind or disabled, the state requires a separate Medicaid application and determines Ònancial eligibility based on SSI income and resource methodologies. The state requires all individuals who seek Medicaid eligibility on the basis of being aged, blind or disabled, including SSI beneÒciaries, to Òle a separate Medicaid application, and determines Ònancial eligibility based on SSI income and resource methodologies. The state requires all individuals who seek Medicaid eligibility on the basis of being aged, blind or disabled, including SSI beneÒciaries, to Òle a separate Medicaid application, and determines Ònancial eligibility using income and resource methodologies more restrictive than SSI. iv. Quarterly v. Yearly Not Started In Progress Complete The state determines Ònancial eligibility consistent with the methodologies described in 42 C.F.R. §435.601. SSA Eligibility Determination State (1634 State) State Eligibility Determination (SSI Criteria State) State Eligibility Determination (209(b) State)
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1/11/2018 TX - Submission Package - TX2017MS0004O - (TX-17-0024) - Eligibility https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0cLS686GhhLQgRf5E7z-wNvEPIQRVzvbAgHdSwtu_ygqyMOESN3NPjfrnNOf-y8z2zcfsTLRYBxWG1nzc8TFRJy/v… 10/14 C. Financial Responsibility of Relatives D. Additional Information (optional) Medicaid State Plan Eligibility Mandatory Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | TX2017MS0004O | TX-17-0024 Package Header Package ID TX2017MS0004O Submission Type OÕcial Approval Date 12/13/2017 Superseded SPA ID TX-14-0002 System-Derived SPA ID TX-17-0024 Initial Submission Date 9/29/2017 E×ective Date 8/1/2017 Mandatory Coverage A. The state provides Medicaid to mandatory groups of individuals. The mandatory groups covered are: Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package Included in Another Submission Package Source Type Infants and Children under Age 19 CONVERTED Parents and Other Caretaker Relatives APPROVED Pregnant Women CONVERTED Deemed Newborns NEW Children with Title IV-E Adoption Assistance, Foster Care or Guardianship Care NEW Former Foster Care Children CONVERTED Transitional Medical Assistance NEW Extended Medicaid due to Spousal Support Collections NEW The state determines the Ònancial responsibility of relatives consistent with the requirements and methodologies described in 42 C.F.R. §435.602. Not Started In Progress Complete
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1/11/2018 TX - Submission Package - TX2017MS0004O - (TX-17-0024) - Eligibility https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0cLS686GhhLQgRf5E7z-wNvEPIQRVzvbAgHdSwtu_ygqyMOESN3NPjfrnNOf-y8z2zcfsTLRYBxWG1nzc8TFRJy/vi… 11/14 Aged, Blind and Disabled Eligibility Group Name Covered In State Plan Include RU In Package Included in Another Submission Package Source Type SSI BeneÒciaries NEW Individuals Receiving Mandatory State Supplements NEW Individuals Who Are Essential Spouses NEW Institutionalized Individuals Continuously Eligible Since 1973 NEW Blind or Disabled Individuals Eligible in 1973 NEW Individuals Who Lost Eligibility for SSI/SSP Due to an Increase in OASDI BeneÒts in 1972 NEW Individuals Who Would be Eligible for SSI/SSP but for OASDI COLA increases since April, 1977 NEW Disabled Widows and Widowers Ineligible for SSI due to Increase in OASDI NEW Disabled Widows and Widowers Ineligible for SSI due to Early Receipt of Social Security NEW Working Disabled under 1619(b) NEW Disabled Adult Children NEW QualiÒed Medicare BeneÒciaries NEW QualiÒed Disabled and Working Individuals NEW SpeciÒed Low Income Medicare BeneÒciaries NEW Qualifying Individuals NEW B. The state elects the Adult Group, described at 42 C.F.R. §435.219. C. Additional Information (optional)
Yes No
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1/11/2018 TX - Submission Package - TX2017MS0004O - (TX-17-0024) - Eligibility https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0cLS686GhhLQgRf5E7z-wNvEPIQRVzvbAgHdSwtu_ygqyMOESN3NPjfrnNOf-y8z2zcfsTLRYBxWG1nzc8TFRJy/v… 12/14 Eligibility Groups Deselected from Coverage The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: N/A Medicaid State Plan Eligibility Eligibility Groups - Mandatory Coverage Parents and Other Caretaker Relatives MEDICAID | Medicaid State Plan | Eligibility | TX2017MS0004O | TX-17-0024 Parents and other caretaker relatives of dependent children with household income at or below a standard established by the state. Package Header Package ID TX2017MS0004O Submission Type OÕcial Approval Date 12/13/2017 Superseded SPA ID TX-14-0002 System-Derived SPA ID TX-17-0024 Initial Submission Date 9/29/2017 E×ective Date 8/1/2017 The state covers the mandatory parents and other caretaker relatives group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Are parents or other caretaker relatives (deÒned at 42 CFR 435.4), including pregnant women, of dependent children (deÒned at 42 CFR 435.4) under age 18. Spouses of parents and other caretaker relatives are also included. The state elects the following options: Description of other relatives: See E Additional Information Not Started In Progress Complete a. This eligibility group includes individuals who are parents or other caretakers of children who are 18 years old, provided the children are full-time students in a secondary school or the equivalent level of vocational or technical training. b. Options relating to the deÒnition of caretaker relative: i. The deÒnition of caretaker relative includes the domestic partner of the parent or other caretaker relative, even after the partnership is terminated. ii. The deÒnition of caretaker relative includes other relatives of the child based on blood (including those of half-blood), adoption or marriage. iii. The deÒnition of caretaker relative includes any adult with whom the child is living and who assumes primary responsibility for the dependent child's care. c. Options relating to the deÒnition of dependent child: i. The state elects to eliminate the requirement that a dependent child must be deprived of parental support or care by reason of the death, physical or mental incapacity, or absence from the home or unemployment of at least one parent. ii. The child must be deprived of parental support or care, but a less restrictive standard is used to measure unemployment of the parent (select the one that applies):
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1/11/2018 TX - Submission Package - TX2017MS0004O - (TX-17-0024) - Eligibility https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0cLS686GhhLQgRf5E7z-wNvEPIQRVzvbAgHdSwtu_ygqyMOESN3NPjfrnNOf-y8z2zcfsTLRYBxWG1nzc8TFRJy/v… 13/14 2. Have household income at or below the standard established by the state. B. Financial Methodologies MAGI-based methodologies are used in calculating household income. Please refer as necessary to MAGI-Based Methodologies, completed by the state. C. Income Standard Used 1. The income standard for this group is based on a percentage of the federal poverty level. 2. The state uses the following income standard for this group: D. Basis for Income Standard 1. Minimum Income Standard a. The minimum income standard used for this group is the state's AFDC payment standard in e×ect as of May 1, 1988, converted to MAGI-equivalent amounts by household size. The standard is described in AFDC Income Standards. 2. Maximum income standard b. The state's maximum income standard for this eligibility group is: c. The amount of the maximum income standard is: E. Additional Information (optional) A person meets the relationship requirement if the person is by law, marriage, or adoption a child's father or mother; grandparent, to the degree of a "great, great, great" grandparent; brother or sister; uncle or aunt, to the degree of a "great, great" uncle or aunt; Òrst cousin; nephew or niece, to the degree of a "great, great" nephew or niece; stepfather or stepmother; stepbrother or stepsister; or Òrst cousin once removed.
Yes No a. The state's AFDC payment standard in e×ect as of May 1, 1988, converted to MAGI-equivalent amounts by household size. The standard is described in AFDC Income Standards. b. The state certiÒes that it has submitted and received approval for its converted May 1, 1988 AFDC payment standard. a. The state certiÒes that it has submitted and received approval for its converted income standard(s) for parents and other caretaker relatives to MAGI-equivalent standards and the determination of the maximum income standard to be used for parents and other caretaker relatives under this eligibility group. i. The state's e×ective income level for section 1931 families under the Medicaid state plan as of March 23, 2010, converted to a MAGI-equivalent percent of FPL or amounts by household size. ii. The state's e×ective income level for section 1931 families under the Medicaid state plan as of December 31, 2013, converted to a MAGI-equivalent percent of FPL or amounts by household size. iii. The state's e×ective income level for any population of parents/caretaker relatives under a Medicaid 1115 demonstration as of March 23, 2010, converted to a MAGI- equivalent percent of FPL or amounts by household size. iv. The state's e×ective income level for any population of parents/caretaker relatives under a Medicaid 1115 demonstration as of December 31, 2013, converted to a MAGI- equivalent percent of FPL or amounts by household size. i. A percentage of the federal poverty level: ii. The state's AFDC payment standard in e×ect as of July 16, 1996, converted to a MAGI-equivalent standard. The standard is described in AFDC Income Standards. iii. The state's AFDC payment standard in e×ect as of July 16, 1996, increased by no more than the percentage increase in the Consumer Price Index for urban consumers (CPI- U) since such date, converted to a MAGI-equivalent standard. The standard is described in AFDC Income Standards. iv. The state's TANF payment standard, converted to a MAGI-equivalent standard. The standard is described in AFDC Income Standards. v. Other dollar amount
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1/11/2018 TX - Submission Package - TX2017MS0004O - (TX-17-0024) - Eligibility https://macpro.cms.gov/suite/tempo/records/item/lUB9Co0jznkfJLyQF9e4HpiqLQ9Q0cLS686GhhLQgRf5E7z-wNvEPIQRVzvbAgHdSwtu_ygqyMOESN3NPjfrnNOf-y8z2zcfsTLRYBxWG1nzc8TFRJy/v… 14/14 Additional Information Related to TANF work requirements: The state terminates medical assistance (except for certain pregnant women and children) for individuals who fail to meet TANF work requirements. PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance OÕcer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 1/11/2018 9:54 AM EST
(spa)(tx-18-0001)(approval-document)Texas Medicaid SPA TX-18-0001: Approval Document (approved May 15, 2018, effective February 15, 2018)#
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Table of Contents State/Territory Name: Texas State Plan Amendment (SPA) #: 18-0001 Pharm SPA This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Superseding Page Listing 4) Approved Page
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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, MailStop 52--14-26 Baltirrrore, Maryland 212M-^1850 Center for Medicaid and CHIP Services uts ctÑlttrg Fo¡ MEotcr¡E & MEDt(}lD tt[vtcÊs CENTIR fOBMEDICAIO & CRTP ÊERVIC;S Disabled and Elderþ Health Programs Group May 15,2018 Ms Stephanie Muth State Medicaid Director Post Office Box 13247, MC: H-100 Austin, TX 7871 1 Dear Ms Muth: We have reviewed Texas's State Plan Amendment (SPA) 18-0001, Prescribed Drugs, received in the Dallas Regional Office on Februty 20,2018. This SPA updates the section of the State Plan that addresses the State Medicaid Supplemental Drug Rebate Agreements. Section 1927 of the Social Security Act authorizes Texas Health & Huma¡ Services to enter into Supplemental Rebate Agreements \À¡ith drug manufacturers to obtain rebates for covered drugs in addition to the rebates already collected under the Medicaid Drug Rebate Program. Based on the information provided and consistent with the regulations at 42 CFP. 430 .20 , we are pleased to inform you that SPA 18-0001 is approved with an effective date of February 15,2018. A copy ofthe signed CMS-179 form, as well as the pages approved for incorporation into Texas's state plan will be forwarded by the Dallas Regional Office. Ifyou have any questions regarding this amendment, please contact Pamela Schweitzer at (4 10) 7 86-2832 or oamela.schweitzer@cms.hhs.sov. Sincerely -- l/hn l,t. Coster. Ph.D.. R.Ph. Director, Division of Pharmacy CC: Bill Brooks, ARA, CMS, Dallas Regional Office Billy Bob Farrell, CMS, Dallas Regional Office Ford Blunt, CMS, Dallas Regional Office Beren Dutra, Texas Health & Human Services
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February 20, 2018 May 15, 2018 February 15, 2018 Bill Brooks Associate Regional Administrator Division of Medicaid and Children's Health
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Attachment to Blocks 8 & 9 of CMS Form 179
Transmittal Number 18-0001
Number of the Number of the Superseded Plan Section or Attachment Plan Section or Attachment
Appendix 1 to Attachment 3.1-A Appendix 1 to Attachment 3.1-A Page 24a Page 24a (TN 15-0022)
Appendix 1 to Attachment 3.1-B Appendix 1 to Attachment 3.1-B Page 24a Page 24a (TN 15-0022)
State: Texas Date Received: 02-20-18 Date Approved: 05-15-18 Date Effective: 02-15-18 Transmittal Number: 18-0001
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State of Texas Appendix 1 to Attachment 3.1-A TN: ____________ Approval Date: __________ Supersedes TN: ____________ Effective Date: __________ Page 24a 12a. Prescribed Drugs (4) A program benefit offered by the manufacturer or labeler of the drug partially or wholly in lieu of a supplemental rebate and accepted by the state; and (5) Written evidence offered by a manufacturer or labeler supporting the inclusion of a product on the PDL. The state will examine information from any or all of these sources when considering the drugs to be included in the PDL. The state will only include on the PDL drugs provided by a manufacturer or labeler that: (1) has reached an agreement with the state for supplemental rebates for drugs provided to Medicaid recipients; or (2) has not reached an agreement for supplemental rebates, if the state determines that inclusion of the drug on the PDL will have no negative cost impact. Manufacturers or labelers that offer a program benefit must first have a supplemental rebate agreement. (f) Supplemental Medicaid Drug Rebate Agreement: Pursuant to Section 1927 of the Act, the state has the following policies for Medicaid supplemental rebates and program benefits: (1) A model agreement between the state and a drug manufacturer for drugs provided to the Medicaid population, effective February 15, 2018, and entitled "Texas Health and Human Services Commission, Title XIX Vendor Drug Program, Supplemental Rebate Agreement," has been authorized by CMS. (2) Supplemental rebates received by the state in excess of those required under the national drug rebate agreement will be shared with the federal government on the same percentage basis as applied under the national rebate agreement. (3) A model program benefit agreement between the state and the drug manufacturer for program benefits provided to the Medicaid program, submitted to CMS on September 14, 2004 and entitled "Texas Health and Human Services Commission Title XIX Vendor Drug Program Benefit Agreement" has been authorized by CMS. (4) Program benefits will consist of benefits, services, or expenditures that the state would otherwise bear under its state plan as medical or administrative expense. 18-0001 05-15-18 02-15-18 15-0022 State: Texas Date Received: 02-20-18 Date Approved: 05-15-18 Date Effective: 02-15-18 Transmittal Number: 18-0001
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State of Texas Appendix 1 to Attachment 3.1-B TN: ____________ Approval Date: __________ Supersedes TN: ____________ Effective Date: __________ Page 24a 12a. Prescribed Drugs (4) A program benefit offered by the manufacturer or labeler of the drug partially or wholly in lieu of a supplemental rebate and accepted by the state; and (5) Written evidence offered by a manufacturer or labeler supporting the inclusion of a product on the PDL. The state will examine information from any or all of these sources when considering the drugs to be included in the PDL. The state will only include on the PDL drugs provided by a manufacturer or labeler that: (1) has reached an agreement with the state for supplemental rebates for drugs provided to Medicaid recipients; or (2) has not reached an agreement for supplemental rebates, if the state determines that inclusion of the drug on the PDL will have no negative cost impact. Manufacturers or labelers that offer a program benefit must first have a supplemental rebate agreement. (f) Supplemental Medicaid Drug Rebate Agreement: Pursuant to Section 1927 of the Act, the state has the following policies for Medicaid supplemental rebates and program benefits: (1) A model agreement between the state and a drug manufacturer for drugs provided to the Medicaid population, effective February 15, 2018, and entitled "Texas Health and Human Services Commission, Title XIX Vendor Drug Program, Supplemental Rebate Agreement," has been authorized by CMS. (2) Supplemental rebates received by the state in excess of those required under the national drug rebate agreement will be shared with the federal government on the same percentage basis as applied under the national rebate agreement. (3) A model program benefit agreement between the state and the drug manufacturer for program benefits provided to the Medicaid program, submitted to CMS on September 14, 2004 and entitled "Texas Health and Human Services Commission Title XIX Vendor Drug Program Benefit Agreement" has been authorized by CMS. (4) Program benefits will consist of benefits, services, or expenditures that the state would otherwise bear under its state plan as medical or administrative expense. 18-0001 05-15-18 02-15-18 15-0022 State: Texas Date Received: 02-20-18 Date Approved: 05-15-18 Date Effective: 02-15-18 Transmittal Number: 18-0001
(spa)(tx-19-0007)(approval-document)Texas Medicaid SPA TX-19-0007: Approval Document (approved May 7, 2019, effective March 1, 2019)#
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Table of Contents State/Territory Name: Texas State Plan Amendment (SPA) #: 19-007 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved Page
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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 1301 Young Street Dallas, Texas 75202
Regional Operations Group
May 7, 2019
Our Reference: TX SPA 19-0007
Ms. Stephanie Muth State Medicaid Director Texas Health and Human Services Commission Mail Code: H100 Post Office Box 13247 Austin, TX 78711
Dear Ms. Muth:
We have reviewed the State’s proposed amendment to the Texas State Plan submitted under Transmittal Number 19-0007, dated March 22, 2019. This state plan amendment updates the physicians’ and other practitioners’ state plan pages by identifying the new conversion factor (CF) for anesthesia services provided by certain children's hospitals.
Based on the information submitted, we have approved the amendment for incorporation into the official Texas State Plan with an effective date change of March 1, 2019. A copy of the CMS-179 and approved plan pages are enclosed with this letter.
If you have any questions, please contact Ford Blunt of my staff. Mr. Blunt may be reached at (214) 767-6381 or by e-mail at Ford.Blunt@cms.hhs.gov.
Sincerely,
Bill Brooks Director Centers for Medicaid & CHIP Services Regional Operations Group
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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE AND MEDICAID SERVICES TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE AND MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Circle One): 1. TRANSMITTAL NUMBER: 19-0007 FORM APPROVED OMB NO 0938-0193 2. STATE: TEXAS 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED EFFECTIVE DATE: March 1, 2019 D NEW STATE PLAN D AMENDMENT TO BE CONSIDERED AS NEW PLAN ~ AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: SEE ATTACHMENT Social Security Act §1902(a)(30); 42 CFR 447.201(b) a. FFY 2019 $1,047,243 b. FFY 2020 $1,892,287 c. FFY 2021 $1,911,967 8. PAGE NUMBER OF THE PLAN SECTION OR 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION ATTACHMENT: OR ATTACHMENT (If Applicable): SEE ATTACHMENT TO BLOCKS 8 & 9 SEE ATTACHMENT TO BLOCKS 8 & 9 10. SUBJECT OF AMENDMENT: The proposed amendment updates the physicians' and other practitioners' state plan pages by identifying the new conversion factor (CF) for anesthesia services provided by certain children's hospitals. 11. GOVERNOR'S REVIEW (Check One): D GOVERNOR'S OFFICE REPORTED NO COMMENT ~ OTHER, AS SPECIFIED: Sent to Governor's Office this date. Comments, if any, will be forwarded upon receipt. D COMMENTS OF GOVERNOR'S OFFICE ENCLOSED D NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 1~~F:dGENCY OFFICIAL: 16. RETURN TO: Stephanie Muth 13.YI"VPE~ NAME: State Medicaid Director Stephanie Muth Post Office Box 13247, MC: H-100 Austin, Texas 78711 14. TITLE: State Medicaid Director 15. DATE SUBMITTED: March 22, 2019 FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: 18. DATE APPROVED: PLAN APPROVED- ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 20. SIGNATURE OF REGIONAL OFFICIAL: 21. TYPED NAME: 22. TITLE: 23. REMARKS: FORM CMS 179 (07-92) March 22, 2019 May 7, 2019 March 1, 2019 Bill Brooks Director Regional Operations Group
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Attachment to Blocks 8 & 9 of CMS Form 179 Transmittal Number 19-0007 Number of the Number of the Superseded Plan Section or Attachment Plan Section or Attachment Attachment 4.19-B Attachment 4.19-B Page 1a.2 Page 1a.2 (TN 19-0001) Page 1a.3 Page 1a.3 (TN 19-0004) State: Texas Date Received: 03-22-19 Date Approved: 05-07-19 Date Effective: 03-01-19 Transmittal Number: 19-0007
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TN: ___________ Approval Date: _________ Supersedes TN: ___________ Effective Date: _________ State of Texas Attachment 4.19-B Page 1a.2 1. Physicians and Other Practitioners (continued) F. Conversion factor equal to the current Medicare conversion factor – Effective April 1, 2010, for increases to certain RBFs for services provided by physicians and other practitioners. Implemented with respect to maintaining access to care for Medicaid clients for certain necessary medical services. G. $25.60 – Effective November 1, 2017, for anesthesia services to clients under age 21. H. $24.32 – Effective November 1, 2017, for anesthesia services to clients 21 years of age and older. I. $34.00 – Effective March 1, 2019, for anesthesia services to clients under 21 years of age and paid to children’s hospitals when the care team model is utilized, and the following criteria are met: • Level I/Level II trauma facility at separately-licensed children’s hospital, and • Level IV NICU, and • Not-for-profit, and • A minimum Medicaid utilization rate of 40 percent. (d) Access-based fees (ABFs) are developed to account for deficiencies in RBFs relating to adequacy of access to health care services for Medicaid clients and are based upon: (1) historical charges; (2) current total Medicare fee (i.e., RVU times Conversion Factor) for the individual service; (3) review of Medicaid fees paid by other states; (4) survey of providers' costs to provide the individual service; (5) Medicaid fees for similar services; and/or (6) some combination or percentage thereof. (e) General guidelines used when updating Medicaid fees for services provided by physicians and other practitioners, include, but not limited to the following: updating the Medicaid relative value units (RVUs) to those currently in effect for Medicare and multiplying the updated RVUs by the current Medicaid conversion factor to result in an updated resource-based fee (RBF); increasing the Medicaid conversion factor to increase RBFs for which no RVU update is required in order to increase access to services; changing an existing RBF to an access-based fee (ABF) when the RBF methodology does not provide sufficient access to care; and changing an existing ABF to a RBF as appropriate. 19-0007 05-07-19 03-01-19 19-0001 State: Texas Date Received: 03-22-19 Date Approved: 05-07-19 Date Effective: 03-01-19 Transmittal Number: 19-0007
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TN: ___________ Approval Date: _________ Supersedes TN: ___________ Effective Date: _________ State of Texas Attachment 4.19-B Page 1a.3 1. Physicians and Other Practitioners (continued) (f) When a procedure code is nationally discontinued, a replacement procedure code is nationally assigned for the discontinued procedure code, and Medicaid implements the replacement procedure code, a state plan amendment will not be submitted since the fee for the service has not changed. (g) To ensure access to care and prompt provider reimbursement, when a new national procedure code is assigned to a physician-administered drug or biological product, a preliminary reimbursement rate will be established by the Texas Health and Human Services Commission (HHSC) based on the published Medicare reimbursement rate; or the average wholesale price (AWP) in the absence of a Medicare reimbursement rate for the procedure code or the comparable code. In accordance with 42 CFR §447.205(b)(1), a public notice and state plan amendment will not be submitted for this preliminary reimbursement rate. This will allow the new procedure code to be payable as the reimbursement process is completed with a public notice published and a state plan amendment submitted. (h) All fee schedules are available through the agency’s website, as outlined on Attachment 4.19-B, page 1. (i) The agency’s fee schedule was revised with new fees for services provided by physicians and other practitioners affiliated with tuberculosis clinics or employed by tuberculosis clinics, effective July 1, 2018, and this fee schedule was posted on the agency’s website on July 6, 2018. (j) The agency’s fee schedule was revised with new fees for therapy assistants. Effective December 1, 2017, the reimbursement for therapy assistants will equal 85 percent of the payment to a therapist. Effective September 1, 2018, the reimbursement for therapy assistants will equal 70 percent of the payment to a therapist. (k) The agency’s fee schedule was revised with new fees to include peer specialists effective January 1, 2019, and this fee schedule was posted on the agency’s website on January 7, 2019. (l) The agency’s fee schedule was revised with new fees for physicians and other practitioners effective March 1, 2019, and this fee schedule was posted on the agency’s website on March 8, 2019. 19-0007 05-07-19 03-01-19 19-0004 State: Texas Date Received: 03-22-19 Date Approved: 05-07-19 Date Effective: 03-01-19 Transmittal Number: 19-0007
(spa)(tx-19-0027)(approval-document)Texas Medicaid SPA TX-19-0027: Approval Document (approved October 18, 2019, effective August 1, 2019)#
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Table of Contents State/Territory Name: Texas State Plan Amendment (SPA) #: 19-0027 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved Page
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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 1301 Young Street Dallas, Texas 75202
Regional Operations Group
October 18, 2019
Our Reference: TX SPA 19-0027
Ms. Stephanie Muth State Medicaid Director Texas Health and Human Services Commission Mail Code: H100 Post Office Box 13247 Austin, TX 78711
Dear Ms. Muth:
We have reviewed the State’s proposed amendment to the Texas State Plan submitted under Transmittal Number 19-0027, dated September 27, 2019. This state plan amendment updates the durable medical equipment, prosthetics, orthotics, and supplies fee schedules.
Based on the information submitted, we have approved the amendment for incorporation into the official Texas State Plan with an effective date change of August 1, 2019. A copy of the CMS- 179 and approved plan page are enclosed with this letter.
If you have any questions, please contact Ford Blunt of my staff. Mr. Blunt may be reached at (214) 767-6381 or by e-mail at Ford.Blunt@cms.hhs.gov.
Sincerely,
Bill Brooks Director Regional Operations Group for
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DEPARTMENT OF HEAL TH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE AND MEDICAID SERVICES TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE AND MEDICAID SERVICES DEPARTMENT OF HEAL TH AND HUMAN SERVICES 5. TYPE OF PLAN MATERIAL (Circle Ona): 1. TRANSMITIAL NUMBER: 19-0027 FORM APPROVED 0MB NO 0938-0193 2. STATE: TEXAS 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED EFFECTIVE DATE: August 1, 2019 0 NEW STATE PLAN 0 AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: SEE ATTACHMENT Social Security Act §1902(a) (30); 42 CFR §447.201(b). a. FFY2019 $ 24,193 b. FFY2020 $152,911 c. FFY 2021 $157,519 8. PAGE NUMBER OF THE PLAN SECTION OR 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION ATIACHMENT: OR ATIACHMENT (If Applicable): SEE ATTACHMENT TO BLOCKS 8 & 9 SEE ATTACHMENT TO BLOCKS 8 & 9 10. SUBJECT OF AMENDMENT: The proposed amendment updates the durable medical equipment, prosthetics, orthotics, and supplies fee schedules. 11. GOVERNOR'S REVIEW (Check One): 0 GOVERNOR'S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED: Sent to Governor's Office this date. Comments, if any, will be forwarded upon receipt. 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITIAL 12. / L: 16. RETURN TO: Stephanie Muth 13. TI'FED N'f'iE: / - State Medicaid Director Stephanie Muth Post Office Box 13247, MC: H-100 Austin, Texas 78711 14. TITLE: State Medicaid Director 15. DATE SUBMITIED: September 27, 2019 FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: 18. DATE APPROVED: PLAN APPROVED- ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 20. SIGNATURE OF REGIONAL OFFICIAL: 21. TYPED NAME: 22. TITLE: 23. REMARKS: FORM CMS-179 (07-92) September 27, 2019 October 18, 2019 August 1, 2019 Bill Brooks Director Regional Operations Group for
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Attachment to Blocks 8 & 9 of CMS Form 179 Transmittal Number 19-0027 Number of the Number of the Superseded Plan Section or Attachment Plan Section or Attachment Attachment 4.19-B Attachment 4.19-B Page 3a Page 3a (TN 19-0016) State: Texas Date Received: 09-27-19 Date Approved: 10-18-19 Date Effective: 08-01-19 Transmittal Number: 19-0027
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TN: ____________ Approval Date: ____________ Supersedes TN: ____________ Effective Date: ____________ State of Texas Attachment 4.19-B Page 3a 8. Home Health Services (continued) (b) Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) (1) If the item of DMEPOS is covered by Medicare, the Medicaid fee will be equal to or a percentage of the Medicare fee schedule specific to Texas that is available at the time of the fee review, unless there is documentation that the Medicare fee is insufficient for the items covered under the procedure code and required by the Medicaid population. (2) For items of DMEPOS not paid at the Medicare fee, the provider will either be reimbursed a fee determined by HHSC or through manual pricing. The fee determined by HHSC will be determined from cost information from providers, manufacturers, surveys of the Medicaid fees for other states, survey information from national fee analyzers, or other relevant fee-related information. (3) Manual pricing is reasonable when one procedure code covers a broad range of items with a broad range of costs, since a single fee may not be a reasonable fee for all items covered under the procedure code, resulting in access-to-care issues. Examples include 1) procedure codes with a description of “not otherwise covered,” “unclassified,” or “other miscellaneous;” and 2) procedure codes covering customized items. If manual pricing is used, the provider is reimbursed either the documented Manufacturer's Suggested Retail Price (MSRP) less 18 percent, or the documented Average Wholesale Price (AWP) less 10.5 percent, whichever one is applicable. If one of these is not available, the provider's documented invoice cost is used as the basis for manual pricing. AWP pricing is used primarily for nutritional products and DMEPOS items sold in pharmacies. (4) The Medicaid fees for oxygen equipment, oxygen, and oxygen-related supplies will not exceed the Medicare fee for the same procedure code. (5) All fee schedules are available through the agency’s website as outlined on Attachment 4.19-B, page 1. (6) The agency’s fee schedule was revised with new fees for durable medical equipment, prosthetics, orthotics, and supplies effective August 1, 2019, and was posted on the agency’s website on September 5, 2019. 19-0027 10-18-19 08-01-19 19-0016 State: Texas Date Received: 09-27-19 Date Approved: 10-18-19 Date Effective: 08-01-19 Transmittal Number: 19-0027
(spa)(tx-19-0029)(approval-document)Texas Medicaid SPA TX-19-0029: Approval Document (approved November 7, 2019, effective September 1, 2019)#
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Table of Contents State/Territory Name: Texas State Plan Amendment (SPA) #: 19-0029 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved Page
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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 1301 Young Street, Suite 900 Dallas, Texas 75202
Regional Operations Group
November 7, 2019
Our Reference: TX SPA 19-0029
Ms. Stephanie Muth State Medicaid Director Texas Health and Human Services Commission Mail Code: H100 Post Office Box 13247 Austin, TX 78711
Dear Ms. Muth:
We have reviewed the State’s proposed amendment to the Texas State Plan submitted under Transmittal Number 19-0029, dated September 30, 2019. This amendment updates the home health and personal care services fee schedules.
Based on the information submitted, we have approved the amendment for incorporation into the official Texas State Plan with an effective date change of September 1, 2019. A copy of the CMS- 179, and approved plan page are enclosed with this letter.
If you have any questions, please contact Ford Blunt of my staff. Mr. Blunt may be reached at (214) 767-6381 or by e-mail at Ford.Blunt@cms.hhs.gov.
Sincerely,
Bill Brooks Director Regional Operations Group
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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS flD At.It’AD AMr MEDICAID SERVICES FORM APPROVED 0MB NO. 0938-0193 1. TRANSMITTAL NUMBER: 2. STATE: TRANSMITTAL AND NOTICE OF APPROVAL OF TEXAS STATE PLAN MATERIAL 19-0029 FOR: CENTERS FOR MEDICARE AND MEDICAID SERVICES 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGiONAL ADMINISTRATOR 4. PROPOSED EFFECTiVE DATE: CENTERS FOR MEDICARE AND MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES .eptemrer., 5. TYPE OF PLAN MATERIAL (Circle One): El NEW STATE PLAN El AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: SEE ATTACHMENT Home Health Professional Services: 1905(a)(7) of the Social a. FFY 2019$ 21,339 Security Act; 42 CFR §440.70; Home Health Durable Medical b. FFY 2020 $268,756 Equipment (DME) and Supplies: §1905(a)(7) of the Social C. FFY 2021 $277,051 Security Act; 42 CFR §440.70(b)(3); Prosthetic Devices: §1905(a)f12) of the Social Security Act; 42 CFR § 440.120; Early and Periodic Screening, Diagnosis and Treatment: §1 905(r) of Social Security Act; 42 CFR 440.40. 8. PAGE NUMBER OF THE PLAN SECTION OR 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION ATTACH M ENT: OR ATTACH MENT (If Applicable): SEE ATTACHMENT TO BLOCKS 8 & 9 SEE ATTACHMENT TO BLOCKS 8 & 9 10. SUBJECT OF AMENDMENT: The proposed amendment updates the home health and personal care services fee schedules. 1 1. GOVERNOR’S REVIEW (Check One): El GOVERNOR’S OFFICE REPORTED NO COMMENT OTHER, AS SPECHIEE Sent to Governor’s Office this date. El COMMENTS OF GOVERNOR’S OFFICE ENCLOSED El NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIG E OF STATE AGENCY OFFICIAL: 16. RETURN TO: Stephanie Muth 13. TYPED NA E: State Medicaid Director Stephanie Muth Post Office Box 13247, MC: H-lao Austin, Texas 78711 14. TITLE: State Medicaid Director 15. DATE SUBMITTED: September 30, 2019 FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: [ 18. DATE APPROVED: PLAN APPROVED — ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 20. SiGNATURE OF REGIONAL OFFICIAL: 21. TYPED NAME: 22. TITLE: 23. REMARKS: FORM CMS — 179 (07-92) September 30, 2019 November 7, 2019 September 1, 2019 Bill Brooks Director Regional Operations Group
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Attachment to Blocks 8 & 9 of CMS Form 179 Transmittal Number 19-0029 Number of the Number of the Superseded Plan Section or Attachment Plan Section or Attachment Attachment 4.19-B Attachment 4.19-B
Page 25k.2 Page 25k.2 (TN 15-0028) State: Texas Date Received: 09-30-19 Date Approved: 11-07-19 Date Effective: 09-01-19 Transmittal Number: 19-0029
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TN: ____________ Approval Date: ____________ Supersedes TN: ____________ Effective Date: ____________ State of Texas Attachment 4.19-B Page 25k.2 32. Reimbursement Methodologies for Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services - continued (14) Personal care services (PCS) a) Services reimbursable only for Medicaid-eligible clients under age 21 include those delivered by the following provider types: 1) School districts in accordance with Item 32(17) of Attachment 4.19-B, relating to the reimbursement methodology for School Health and Related Services (SHARS). 2) Home health agencies and other PCS providers delivering PCS in the client's home, excluding services delivered through the Consumer Directed Services service delivery model, are reimbursed the lesser of the provider's billed charges or fees established by the Texas Health and Human Services Commission (HHSC) based on an analysis of relevant cost or fee surveys. Payments based on a fee schedule are made for these services. b) All fee schedules are available through the agency's website as outlined on Attachment 4.19-B, page 1. c) The agency's fee schedule was revised with new fees for EPSDT Personal Care Services effective September 1, 2019. The fee schedule was posted on the agency website on September 5, 2019. 19-0029 11-07-19 09-01-19 15-0028 State: Texas Date Received: 09-30-19 Date Approved: 11-07-19 Date Effective: 09-01-19 Transmittal Number: 19-0029
(spa)(tx-20-0003)(approval-document)Texas Medicaid SPA TX-20-0003: Approval Document (approved August 31, 2020, effective September 1, 2020)#
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Table of Contents State/Territory Name: Texas State Plan Amendment (SPA) #: 20-0003 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved Page
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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 601 E. 12th St., Room 355 Kansas City, Missouri 64106
Medicaid and CHIP Operations Group
08/31/2020 Stephanie Stephens, Medicaid Director Texas Health & Human Services Commission P.O. Box 13247 Austin, TX 78711 RE: TX 20-0003 Adult Mental Health §1915(i) Home and Community-Based Services (HCBS) State Plan Benefit Renewal Dear Ms. Stephens: We are approving your §1915(i) HCBS state plan amendment (SPA), transmittal number #20- 0003. The purpose of this amendment is to renew Texas’ §1915(i) HCBS State Plan benefit. The effective date for this renewal is 9/1/2020. Enclosed is a copy of the approved SPA. Since the state has elected to target the population who can receive the §1915(i) HCBS State Plan benefit, CMS approves this SPA for a five-year period expiring 8/31/2025, in accordance with §1915(i)(7) of the Social Security Act. To renew the §1915(i) HCBS State Plan benefit for an additional five-year period, the state must submit a renewal application to CMS at least 180 days prior to the end of the approval period, by 3/4/2025. CMS’ approval of a renewal request is contingent upon state adherence to federal requirements and the state meeting its objectives with respect to quality improvement and beneficiary outcomes. Per 42 CFR §441.745(a)(i), the state will annually provide CMS with the projected number of individuals to be enrolled in the benefit and the actual number of unduplicated individuals enrolled in the §1915(i) State Plan HCBS in the previous year. Additionally, at least 21 months prior to the end of the five-year approval period, the state must submit evidence of the state’s quality monitoring in accordance with the Quality Improvement Strategy in their approved SPA. The evidence must include data analysis, findings, remediation, and describe any system improvement for each of the §1915(i) requirements.
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Ms. Stephens – Page 2 It is important to note that CMS’ approval of this 1915(i) HCBS state plan benefit renewal solely addresses the state’s compliance with the applicable Medicaid authorities. CMS’ approval does not address the state’s independent and separate obligations under federal laws including, but not limited to, the Americans with Disabilities Act, §504 of the Rehabilitation Act, or the Supreme Court’s Olmstead decision. Guidance from the Department of Justice concerning compliance with the Americans with Disabilities Act and the Olmstead decision is available at http://www.ada.gov/olmstead/q&a_olmstead.htm. If you have any questions concerning this information, please contact me at (206) 615-2356, or your staff may contact Lynn Ward at lynn.ward@cms.hhs.gov or (214) 767-6327. Sincerely, Wendy Hill Petras, Acting Director Division of HCBS Operations and Oversight Enclosure cc: Kathi Montalbano HHSC HHSC Medicaid Waiver Mailbox David Meacham DHCBSO Cynthia Nanes DHCBSO Kathy Poisal CMCS Matt Weaver CMCS Tamara Sampson DRR
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Attachment to Block 7 of CMS Form 179 Transmittal Number 20-0003 Total Fiscal Impact Federal State FFY 2020 $11,259,796 $6,760,945 $4,498,851 FFY 2021 $16,279,709 $9,959,305 $6,320,404 FFY 2022 $21,166,829 $12,980,034 $8,186,795 Projected annual fiscal impact includes the projected HCBS-AMH annual client services costs for Medicaid clients, and the administrative support full time equivalents (FTEs). Distinct annual utilizers are projected to increase in FFY21 by 36% year over year from projected FFY20 distinct utilizers. Utilizers are anticipated to continue to increase by large annual percentages for each fiscal year through FFY25 but at a dampened pace, resulting in a projected annual percent increase for FFY25 of 15%. These projections are based on a combination of time-series statistical forecasting analysis and subject matter expert growth assumptions. Projected increases in the number of annual utilizers are the principal driver of projected cost increases. Total costs are projected to increase at a higher annual trend than caseload due to additional projected cost of service growth. The administrative support cost is calculated based on an annual average salary per FTE times the total number of FTEs. Access to Care Access to care will not be affected and communications with providers will be maintained to address any concerns, should they arise. There were no across-the-board percentage decreases or increases.
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 1 §1915(i) State plan HCBS Approved: Supersedes:71
The state implements the optional 1915(i) State plan Home and Community-Based Services (HCBS) benefit for elderly and disabled individuals as set forth below. 1. Services. (Specify the state’s service title(s) for the HCBS defined under “Services” and listed in Attachment 4.19-B): 2. Concurrent Operation with Other Programs. (Indicate whether this benefit will operate concurrently with another Medicaid authority): Select one: } Not applicable { Applicable Check the applicable authority or authorities:
Services furnished under the provisions of §1915(a)(1)(a) of the Act. The State contracts with a Managed Care Organization(s) (MCOs) and/or prepaid inpatient health plan(s) (PIHP) or prepaid ambulatory health plan(s) (PAHP) under the provisions of §1915(a)(1) of the Act for the delivery of 1915(i) State plan HCBS. Participants may voluntarily elect to receive waiver and other services through such MCOs or prepaid health plans. Contracts with these health plans are on file at the State Medicaid agency. Specify: (a) the MCOs and/or health plans that furnish services under the provisions of §1915(a)(1); (b) the geographic areas served by these plans; (c) the specific 1915(i) State plan HCBS furnished by these plans; (d) how payments are made to the health plans; and (e) whether the 1915(a) contract has been submitted or previously approved. 1915(i) State plan Home and Community-Based Services Administration and Operation Transition Assistance Services (TAS); HCBS Psychosocial Rehabilitation Services; Adaptive Aids; Employment Services; Transportation; Community Psychiatric Supports and Treatment (CPST); Peer Support; Host Home/Companion Care; Supervised Living Services; Assisted Living Services; Supported Home Living; Respite Care; Home Delivered Meals; Minor Home Modifications; Nursing; Substance Use Disorder (SUD) Services; Home and Community-Based Services - Adult Mental Health (HCBS-AMH)- Recovery Management
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 2 §1915(i) State plan HCBS Approved: Supersedes:71
Waiver(s) authorized under §1915(b) of the Act. Specify the §1915(b) waiver program and indicate whether a §1915(b) waiver application has been submitted or previously approved: Specify the §1915(b) authorities under which this program operates (check each that applies):
§1915(b)(1) (mandated enrollment to managed care)
§1915(b)(3) (employ cost savings to furnish additional services)
§1915(b)(2) (central broker)
§1915(b)(4) (selective contracting/limit number of providers)
A program operated under §1932(a) of the Act. Specify the nature of the State Plan benefit and indicate whether the State Plan Amendment has been submitted or previously approved:
A program authorized under §1115 of the Act. Specify the program:
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 3 §1915(i) State plan HCBS Approved: Supersedes:71 3. State Medicaid Agency (SMA) Line of Authority for Operating the State plan HCBS. Benefit-(Select one): The State plan HCBS benefit is operated by the SMA. Specify the SMA division/unit that has line authority for the operation of the program (select one): The Medical Assistance Unit (name of unit): Another division/unit within the SMA that is separate from the Medical Assistance Unit (name of division/unit) This includes administrations/divisions under the umbrella agency that have been identified as the Single State Medicaid Agency. Health and Human Services Commission Intellectual and Developmental Disability and Behavioral Health Services Department The State plan HCBS benefit is operated by (name of agency) a separate agency of the state that is not a division/unit of the Medicaid agency. In accordance with 42 CFR §431.10, the Medicaid agency exercises administrative discretion in the administration and supervision of the State plan HCBS benefit and issues policies, rules and regulations related to the State plan HCBS benefit. The interagency agreement or memorandum of understanding that sets forth the authority and arrangements for this delegation of authority is available through the Medicaid agency to CMS upon request.
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 4 §1915(i) State plan HCBS Approved: Supersedes 71 4. Distribution of State plan HCBS Operational and Administrative Functions. 俶 (By checking this box the state assures that): When the Medicaid agency does not directly conduct an administrative function, it supervises the performance of the function and establishes and/or approves policies that affect the function. All functions not performed directly by the Medicaid agency must be delegated in writing and monitored by the Medicaid Agency. When a function is performed by an agency/entity other than the Medicaid agency, the agency/entity performing that function does not substitute its own judgment for that of the Medicaid agency with respect to the application of policies, rules and regulations. Furthermore, the Medicaid Agency assures that it maintains accountability for the performance of any operational, contractual, or local regional entities. In the following table, specify the entity or entities that have responsibility for conducting each of the operational and administrative functions listed (check each that applies): (Check all agencies and/or entities that perform each function): Function Medicaid Agency Other State Operating Agency Contracted Entity Local Non- State Entity 1 Individual State plan HCBS enrollment ;
2 Eligibility evaluation ;
3 Review of participant service plans ;
4 Prior authorization of State plan HCBS ;
5 Utilization management ;
6 Qualified provider enrollment ;
7 Execution of Medicaid provider agreement ;
8 Establishment of a consistent rate methodology for each State plan HCBS ;
9 Rules, policies, procedures, and information development governing the State plan HCBS benefit ;
10Quality assurance and quality improvement activities ;
(Specify, as numbered above, the agencies/entities (other than the SMA) that perform each function):
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 5 §1915(i) State plan HCBS Approved: Supersedes:71 (By checking the following boxes the State assures that): 5. 俶 Conflict of Interest Standards. The state assures the independence of persons performing evaluations, assessments, and plans of care. Written conflict of interest standards ensure, at a minimum, that persons performing these functions are not: x related by blood or marriage to the individual, or any paid caregiver of the individual x financially responsible for the individual x empowered to make financial or health-related decisions on behalf of the individual x providers of State plan HCBS for the individual, or those who have interest in or are employed by a provider of State plan HCBS; except, at the option of the state, when providers are given responsibility to perform assessments and plans of care because such individuals are the only willing and qualified entity in a geographic area, and the state devises conflict of interest protections. (If the state chooses this option, specify the conflict of interest protections the state will implement): HHSC ensures that conflicts of interest do not occur. The individuals performing the independent assessments, reassessments, and Person Centered Service Plans (AKA Individual Recovery Plans) (IRP)s cannot also be providers of HCBS-AMH on the IRP or under the administrative control of a provider of HCBS-AMH on the IRP unless the provider is the only willing and qualified entity in a geographic area who can be responsible for assessments and person-centered service plan development. The individuals performing the assessments and IRPs are HHSC employees or contractors who are delegated this responsibility. Contractors must have the requisite experience and skill to perform assessments and/or IRPs. For assessments and person-centered service plan development, the contractors may be public or private sector entities, but may not be HCBS–AMH providers, unless they are the only willing and qualified entity in a geographic area who can be responsible for assessments and person-centered service plan development. The needs-based assessments are reviewed by HHSC staff pursuant to the 1915(i) Quality Improvement Strategy (QIS) requirements listed later in this state plan. HHSC will annually review contractors who complete assessments and IRPs to ensure that they do not have an interest in or are under the control of a provider on the IRP. Contractors delegated the responsibility to perform assessments who are an HCBS-AMH provider of last resort will have a higher level of scrutiny. IRPs will be completed by recovery managers. Recovery management may only be provided by agencies and individuals employed by agencies who are not providers of other HCBS-AMH services for the individual, or those who have interest in or are employed by a provider of HCBS-AMH on the IRP. On occasion the State anticipates exceptions may be necessary in which the recovery management provider for the individual is employed by a provider of other HCBS-AMH services on the IRP as the provider of last resort. Recovery management may only be provided by the provider of last resort when they are the only willing and qualified entity in a geographic area who can be responsible for the development of the person-centered service plan. Recovery management will only be provided by the provider of last resort when there is no other willing and qualified non-provider entity to perform these functions. Texas anticipates that some service areas may not have separate Provider Agencies and Recovery Management Entities, who develop the person-centered service plans that meet requirements of the program and provider agreement. HHSC will enroll HCBS-AMH Provider Agencies and Recovery Management entities through separate Open Enrollments and will actively recruit both types of entities with consideration for counties where Recovery Management Providers are serving as the recovery management provider of last resort. The state anticipates the provision of recovery management by recovery management provider of last resort and instances in which contractors delegated the responsibility to perform assessments are an HCBS-AMH provider of last resort will occur in health manpower shortage areas, combined with rural and frontier counties. • Health manpower shortage area designations can be found at: http://hpsafind.hrsa.gov/ • Rural county designations can be found at: http://www.dshs.texas.gov/chs/hprc/counties.shtm • Frontier and Remote Area Codes as identified by the Economic Research Service of the United States Department of Agriculture can be found at: https://www.ers.usda.gov/data-products/frontier-and-remote- area-codes/
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 6 §1915(i) State plan HCBS Approved: Supersedes:71 6. 俶 Fair Hearings and Appeals. The state assures that individuals have opportunities for fair hearings and appeals in accordance with 42 CFR 431 Subpart E. 7. 俶 No FFP for Room and Board. The state has methodology to prevent claims for Federal financial participation for room and board in State plan HCBS. 8. 俶 Non-duplication of services. State plan HCBS will not be provided to an individual at the same time as another service that is the same in nature and scope regardless of source, including Federal, state, local, and private entities. For habilitation services, the state includes within the record of each individual an explanation that these services do not include special education and related services defined in the Individuals with Disabilities Education Improvement Act of 2004 that otherwise are available to the individual through a local education agency, or vocational rehabilitation services that otherwise are available to the individual through a program funded under §110 of the Rehabilitation Act of 1973. In lieu of denying an individual residence in his/her community of choice due to lack of available Provider Agencies and Recovery Management Entities, the State foresees that in this circumstance an HCBS provider of last resort may also provide recovery management services with certain conflict of interest protections in place. When an HCBS provider of last resort also provides recovery management services, HHSC will require a clear separation of provider and recovery management functions. The distinct individual staff providing recovery management must be administratively separate from other HCBS-AMH provider functions and any related utilization review units and functions. Recovery Managers who work for provider agencies that are providing other HCBS-AMH services as the provider of last resort will not be providers of any other HCBS-AMH service on the IRP. HHSC reviews the administrative structure of the HCBS-AMH agency to ensure that there is a clear administrative separation of recovery management and HCBS-AMH provider staff/functions before approving a provider to serve as a recovery manager, and periodically reviews (including unannounced site-reviews) the individuals performing recovery management to ensure that they are not providers of HCBS-AMH and not under the administrative control of units providing HCBS-AMH services. HHSC will also review resulting IRPs to ensure that there is no conflict of interest. The following conflict mitigation strategies are utilized by HHSC: • Individual staff performing the assessments shall not be under the same administrative authority of staff providing HCBS-AMH or developing the IRP. • Restricting the entity that develops the person-centered service plan from providing services without the direct approval of the state. • Requiring the recovery management entity that develops the IRP to be administratively separate the plan development function from the direct service provider functions. • Assuring that individuals can advocate for themselves or have an advocate present in planning meetings. • Full disclosure to participants and assurance that participants are supported in exercising their right to free choice of providers and are provided information about the full range of HCBS-AMH services, not just the services furnished by the recovery management entity that is responsible for development of the IRP. • Having clear, well-known, and easily accessible means for individuals to make grievances and/or appeals to the State for assistance regarding concerns about choice, quality, and outcomes. This includes a consumer bill of rights for mental health; published rules on consumer rights; a toll-free line staffed by dedicated Consumer Rights representatives who can answer questions about rights, and assist the individual in resolving issues with mental health HCBS services or with filing a complaint regarding services. HHSC’s client ombudsman office is also available via toll-free line to assist consumers in resolving issues with Medicaid providers or services. Information on these rights and grievance/appeal processes will be provided in writing to each individual enrolled in the HCBS program. • Documenting the number and types of appeals and the decisions regarding grievances and/or appeals. • Conducting annual on-site reviews, desk reviews, and analysis of aggregate and individual data. • Documenting consumer experiences with measures that capture the quality of IRP development
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 7 §1915(i) State plan HCBS Approved: Supersedes:71 1. Projected Number of Unduplicated Individuals To Be Served Annually. (Specify for year one. Years 2-5 optional): Annual Period From To Projected Number of Participants Year 1 09/01/2020 08/31/2021 266 Year 2 09/01/2021 08/31/2022 344 Year 3 09/01/2022 08/31/2023 420 Year 4 09/01/2023 08/31/2024 496 Year 5 09/01/2024 08/31/2025 571 2. 俶 Annual Reporting. (By checking this box the state agrees to): annually report the actual number of unduplicated individuals served and the estimated number of individuals for the following year. 1. 俶 Medicaid Eligible. (By checking this box the state assures that): Individuals receiving State plan HCBS are included in an eligibility group that is covered under the State’s Medicaid Plan and have income that does not exceed 150% of the Federal Poverty Line (FPL). (This election does not include the optional categorically needy eligibility group specified at §1902(a)(10)(A)(ii)(XXII) of the Social Security Act. States that want to adopt the §1902(a)(10)(A)(ii)(XXII) eligibility category make the election in Attachment 2.2-A of the state Medicaid plan.) 2. Medically Needy (Select one): 俶The State does not provide State plan HCBS to the medically needy. The State provides State plan HCBS to the medically needy. (Select one): The state elects to disregard the requirements section of 1902(a)(10)(C)(i)(III) of the Social Security Act relating to community income and resource rules for the medically needy. When a state makes this election, individuals who qualify as medically needy on the basis of this election receive only 1915(i) services. The state does not elect to disregard the requirements at section 1902(a)(10)(C)(i)(III) of the Social Security Act. Number Served Financial Eligibility
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 8 §1915(i) State plan HCBS Approved: Supersedes: 71 1. Responsibility for Performing Evaluations / Reevaluations. Eligibility for the State plan HCBS benefit must be determined through an independent evaluation of each individual). Independent evaluations/reevaluations to determine whether applicants are eligible for the State plan HCBS benefit are performed (Select one): } Directly by the Medicaid agency { By Other (specify State agency or entity under contract with the State Medicaid agency): 2. Qualifications of Individuals Performing Evaluation/Reevaluation. The independent evaluation is performed by an agent that is independent and qualified. There are qualifications (that are reasonably related to performing evaluations) for the individual responsible for evaluation/reevaluation of needs- based eligibility for State plan HCBS. (Specify qualifications): 3. Process for Performing Evaluation/Reevaluation. Describe the process for evaluating whether individuals meet the needs-based State plan HCBS eligibility criteria and any instrument(s) used to make this determination. If the reevaluation process differs from the evaluation process, describe the differences: Evaluation/Reevaluation of Eligibility Licensed Practitioner of the Healing Arts (LPHA) preferred, not required. Bachelor’s degree, masters preferred, from a U.S. accredited college or university with specialization in health services, business administration, human services, public policy, social work or related areas. and Has received HHSC-approved training in evaluating individuals for HCBS-AMH. The evaluation / reevaluation is conducted using the Adult Needs and Strengths Assessment (ANSA) to identify functional needs and determine whether an individual meets the needs-based HCBS eligibility criteria. Criteria evaluated using the ANSA include behavioral health needs, life domain functioning (including assessment of ADLs and IADLs), and functional needs / strengths. Evaluations and reevaluations of eligibility for HCBS will be conducted by HHSC staff .
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 9 §1915(i) State plan HCBS Approved: Supersedes:71 4. 俶 Reevaluation Schedule. (By checking this box the state assures that): Needs-based eligibility reevaluations are conducted at least every twelve months. 5. 俶Needs-based HCBS Eligibility Criteria. (By checking this box the state assures that): Needs-based criteria are used to evaluate and reevaluate whether an individual is eligible for State plan HCBS. The criteria take into account the individual’s support needs, and may include other risk factors: (Specify the needs-based criteria): The criteria take into account the individual’s support needs, and may include other risk factors: An individual is eligible for State Plan HCBS under the HCBS-AMH program if the individual requires: HCBS-AMH level of service to maintain stability, improve functioning, prevent relapse, maintain residence in the community and who is assessed and found that, but for the provision of HCBS for stabilization and maintenance purposes, would decline to prior levels of need, i.e. subsequent medically necessary services and coordination of care for stabilization and maintenance is needed to prevent decline to previous needs-based functioning or previously met the needs-based criteria above and who is assessed and found that, but for the provision of HCBS for stabilization and maintenance purposes, would decline to prior levels of need, i.e. subsequent medically necessary services and coordination of care for stabilization and maintenance is needed to prevent decline to previous needs-based functioning. This need is determined through evaluation and reevaluation of functional need using a standardized instrument (the Adult Needs and Strengths Assessment (ANSA)). Each domain on the ANSA assesses functional needs and strengths. Each item within a domain has four levels, with anchored definitions. The assessor uses these definitions to determine a score which is translated into the following action levels (separate for needs and strengths): For needs: 0= No evidence 1= Watchful waiting/prevention 2= Action 3= Immediate/Intensive Action For strengths: 0= Centerpiece strength 1= Strength that you can use in planning 2= Strength has been identified-must be built 3= No strength identified Individuals must have a level of functional need (ANSA score of 2 or higher) that indicates a need for intervention provided by HCBS-AMH services that is identified by items in one of the following domains assessed by the ANSA: behavioral health, life domain functioning (including ADLs and IADLs), or functional needs and strengths. Inpatient psychiatric criteria, which require that the individual be acutely ill and in need of 24-hour observation, stabilization and intervention, including active supervision by a psychiatrist, are more stringent than HCBS needs-based criteria. Need is also evidenced by meeting one of the following risk categories: 1) A history of extended or repeated stay(s) in an inpatient psychiatric hospital (i.e., three years or more of consecutive or cumulative inpatient psychiatric hospitalization during the five years prior to initial enrollment in HCBS-AMH). Or 2) In the three years prior to initial enrollment in HCBS-AMH two or more psychiatric crises (i.e., inpatient psychiatric hospitalizations and/or outpatient psychiatric crisis that meets inpatient psychiatric criteria) and four or more repeated discharges from correctional facilities. Or 3) In the three years prior to initial enrollment in HCBS-AMH two or more psychiatric crises (i.e., inpatient psychiatric hospitalizations and/or outpatient psychiatric crisis that meets inpatient psychiatric criteria) and fifteen or more total emergency department (ED) visits.
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 10 §1915(i) State plan HCBS Approved: Supersedes:71 6. 俶 Needs-based Institutional and Waiver Criteria. (By checking this box the state assures that): There are needs-based criteria for receipt of institutional services and participation in certain waivers that are more stringent than the criteria above for receipt of State plan HCBS. If the state has revised institutional level of care to reflect more stringent needs-based criteria, individuals receiving institutional services and participating in certain waivers on the date that more stringent criteria become effective are exempt from the new criteria until such time as they no longer require that level of care. (Complete chart below to summarize the needs-based criteria for State Plan HCBS and corresponding more-stringent criteria for each of the following institutions): State plan HCBS needs- based eligibility criteria NF (& NF LOC** waivers) ICF/IID (& ICF/IID LOC waivers) Applicable Hospital* (& Hospital LOC waivers) The individual must: 1. Require HCBS-AMH services to improve or maintain functioning, prevent relapse to a lower level of functioning, and maintain residence in the community; demonstrated by a level of functional need (ANSA score of 2 or higher) that indicates a need for intervention provided by HCBS-AMH services that is identified in one of the following domains assessed by the ANSA: behavioral health, life domain functioning (including ADLs and IADLs), or functional needs and strengths; And 2. Meet one of the following risk categories: a. Demonstrate a history of extended or repeated stay(s) in an inpatient psychiatric hospital (i.e., three years or more of consecutive or cumulative inpatient psychiatric hospitalization during the five years prior to initial enrollment in HCBS- AMH); b. Demonstrate in the three years prior to initial enrollment in HCBS- AMH two or more psychiatric crises (i.e., inpatient psychiatric The individual must: Live in a Medicaid- certified NF for 30 consecutive days or live in the community (for NF LOC waivers) and meet medical necessity requirements (see below) According to Texas rules (40 Tex. Admin. Code §19.2401), an individual must meet both of the following criteria for medical necessity: 1. The individual must demonstrate a medical condition that: * is of sufficient seriousness that the individual's needs exceed the routine care which may be given by an untrained person; and * requires licensed nurses' supervision, assessment, planning, and intervention that is available only in an institution. AND 2. The individual must require medical or nursing services that: *are ordered by a physician; *are dependent upon the individual's documented medical conditions; The individual must: Live in a Medicaid- certified Intermediate Care Facility for Individuals with Intellectual or Developmental Disabilities (ICF-IID) for 30 consecutive days or live in the community (for ICF/IID waivers) and meet medical necessity requirements (see below) 1. Have a diagnosed developmental disability. The term "developmental disability" means a severe, chronic disability of an individual that: * is attributable to a mental or physical impairment or combination of mental and physical impairments; * is manifested before the individual attains age 22; * is likely to continue indefinitely; * results in substantial functional limitations in 3 or more of the following areas of major life activity: (i) Self-care. (ii) Receptive and expressive language. (iii) Learning. (iv) Mobility. (v) Self-direction. (vi) Capacity for independent living. (vii) Economic self- sufficiency; and The individual must: 1. Have a valid diagnosis as listed in the current version of the ICD as the principal admitting diagnosis and one of the following: a.Outpatient therapy or partial hospitalization has been attempted and failed b.A psychiatrist has documented reasons why an inpatient level of care is required. AND 2. The individual must meet at least one of the following criteria: a. The individual is presently a danger to self, demonstrated by at least one of the following: (i) Recent suicide attempt or active suicidal threats with a deadly plan, and there is an absence of appropriate supervision or structure to prevent suicide. (ii) Recent self- mutilative behavior or active threats of same with likelihood of acting on the threat, and there is an absence of appropriate supervision or structure to prevent self- mutilation (i.e., intentionally cutting/burning self). (iii) Active hallucinations or delusions directing or likely to lead to serious self-harm or debilitating psychomotor agitation or
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 11 §1915(i) State plan HCBS Approved: Supersedes:71 hospitalizations and/or outpatient psychiatric crisis that meets inpatient psychiatric criteria) four or more repeated discharges from correctional facilities; c. Demonstrate in the three years prior to initial enrollment in HCBS- AMH two or more psychiatric crises (i.e., inpatient psychiatric hospitalizations and/or outpatient psychiatric crisis that meets inpatient psychiatric criteria) and fifteen or more total emergency department (ED) visits. Note: Individuals in HCBS-AMH are not required to demonstrate the need for services that require 24-hour-a- day medical observation, supervision, and intervention. * require the skills of a registered or licensed vocational nurse; *are provided either directly by or under the supervision of a licensed nurse in an institutional setting; and *are required on a regular basis. Medical necessity and level of institutional need is determined by assessing the individual’s functioning using the Minimum Data Set (MDS), version 3.0. * reflects the individual's need for a combination and sequence of special, interdisciplinary, or generic services, individualized supports, or other forms of assistance that are of lifelong or extended duration and are individually planned and coordinated. AND 2. Require active treatment in an institutional setting specifically designed for treatment of intellectual and developmental disabilities. intellectual disability resulting in a significant inability to care for self. (iv) Significant inability to comply with prescribed medical health regimens due to concurrent psychiatric illness and such failure to comply is potentially hazardous to the life of the individual. b. The individual is a danger to others. This behavior must be attributable to the individual’s specific diagnosis that can be adequately treated only in a hospital setting. This danger is demonstrated by one of the following: (i) Recent life- threatening action or active homicidal threats of same with a deadly plan, and availability of means to accomplish the plan, with likelihood of acting on the threat. (ii) Recent serious assaultive or sadistic behavior or active threats of same with likelihood of acting on the threat, and there is an absence of appropriate supervision or structure to prevent assaultive behavior. (iii) Active hallucinations or delusions directing or likely to lead to serious harm of others. c. The individual exhibits acute onset of psychosis or severe thought disorganization, or there is significant clinical deterioration in the condition of someone with a chronic psychosis, rendering the individual unmanageable and unable to cooperate in treatment, and the individual is in need of assessment and
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 12 §1915(i) State plan HCBS Approved: Supersedes:71 treatment in a safe and therapeutic setting. d. The individual has a severe eating or substance abuse disorder that requires 24- hour-a- day medical observation, supervision, and intervention. e. The individual exhibits severe disorientation of person, place, or time. f. The individual’s evaluation and treatment cannot be carried out safely or effectively in other settings due to severely disruptive behaviors and other behaviors, which may also include physical, psychological, or sexual abuse. g. The individual requires medication therapy or complex diagnostic evaluation where the individual’s level of functioning precludes cooperation with the treatment regimen. h. The individual is involved in the legal system, manifests psychiatric symptoms, and is ordered by a court to undergo a comprehensive assessment in a hospital setting to clarify diagnosis and treatment needs. AND 3. The proposed treatment or therapy requires 24-hour-a- day medical observation, supervision, and intervention and must include all of the following:
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 13 §1915(i) State plan HCBS Approved: Supersedes:71 a. Active supervision by a psychiatrist with the appropriate credentials, as determined by the Texas Medical Board (TMB) or other appropriate entity; b. Implementation of an individualized treatment plan; c. Provision of services that can reasonably be expected to improve the client’s condition or prevent further regression so that a lesser level of care can be implemented; d. Proper treatment of the client’s psychiatric condition requires services on an inpatient basis under the direction of a psychiatrist and is being provided in the least restrictive environment available, and ambulatory care resources available in the community do not meet the client’s needs. e. A history of inpatient admission, repeated discharges from correctional facilities, psychiatric crisis, or ED visits is not sufficient to admit an individual to a psychiatric facility. *Long Term Care/Chronic Care Hospital **LOC= level of care
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 14 §1915(i) State plan HCBS Approved: Supersedes:71 7. 俶䢢䢢Target Group(s). The state elects to target this 1915(i) State plan HCBS benefit to a specific population based on age, disability, diagnosis, and/or eligibility group. With this election, the state will operate this program for a period of 5 years. At least 180 days prior to the end of this 5 year period, the state may request CMS renewal of this benefit for additional 5-year terms in accordance with 1915(i)(7)(C) and 42 CFR 441.710(e)(2). (Specify target group(s)): Option for Phase-in of Services and Eligibility. If the state elects to target this 1915(i) State plan HCBS benefit, it may limit the enrollment of individuals or the provision of services to enrolled individuals in accordance with 1915(i)(7)(B)(ii) and 42 CFR 441.745(a)(2)(ii) based upon criteria described in a phase- in plan, subject to CMS approval. At a minimum, the phase-in plan must describe: (1) the criteria used to limit enrollment or service delivery; (2) the rationale for phasing-in services and/or eligibility; and (3) timelines and benchmarks to ensure that the benefit is available statewide to all eligible individuals within the initial 5-year approval. (Specify the phase-in plan): (By checking the following box the State assures that): 8. 俶 Adjustment Authority. The state will notify CMS and the public at least 60 days before exercising the option to modify needs-based eligibility criteria in accord with 1915(i)(1)(D)(ii). 9. Reasonable Indication of Need for Services. In order for an individual to be determined to need the 1915(i) State plan HCBS benefit, an individual must require: (a) the provision of at least one 1915(i) service, as documented in the person-centered service plan, and (b) the provision of 1915(i) services at least monthly or, if the need for services is less than monthly, the participant requires regular monthly monitoring which must be documented in the person-centered service plan. Specify the state’s policies concerning the reasonable indication of the need for 1915(i) State plan HCBS: i. Minimum number of services. The minimum number of 1915(i) State plan services (one or more) that an individual must require in order to be determined to need the 1915(i) State plan HCBS benefit is: One ii. Frequency of services. The state requires (select one): { The provision of 1915(i) services at least monthly } Monthly monitoring of the individual when services are furnished on a less than monthly basis If the state also requires a minimum frequency for the provision of 1915(i) services other than monthly (e.g., quarterly), specify the frequency: An adult over the age of 18 who meets the following criteria is eligible to receive State Plan HCBS: Serious mental illness (SMI)--An illness, disease, disorder, or condition (other than a sole diagnosis of epilepsy, dementia, substance use disorder, or intellectual or developmental disability) that: (A) substantially impairs an individual’s thought, perception of reality, emotional process, development, or judgment; or (B) grossly impairs an individual’s behavior as demonstrated by recent disturbed behavior.
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 15 §1915(i) State plan HCBS Approved: Supersedes:71 (By checking the following box the State assures that): 1. 俶Home and Community-Based Settings. The State plan HCBS benefit will be furnished to individuals who reside and receive HCBS in their home or in the community, not in an institution. (Explain how residential and non-residential settings in this SPA comply with Federal home and community-based settings requirements at 42 CFR 441.710(a)(1)-(2) and associated CMS guidance. Include a description of the settings where individuals will reside and where individuals will receive HCBS, and how these settings meet the Federal home and community-based settings requirements, at the time of submission and in the future): (Note: In the Quality Improvement Strategy (QIS) portion of this SPA, the state will be prompted to include how the state Medicaid agency will monitor to ensure that all settings meet federal home and community-based settings requirements, at the time of this submission and ongoing.) Texas assures the settings included with this state plan amendment (SPA) renewal will be subject to any provisions or requirements included in Texas' approved statewide transition plan. Texas will implement any required changes upon approval of the statewide transition plan and will make conforming changes to its HCBS state plan when it submits the next amendment or renewal. Individuals will receive HCBS services in the following settings. • Host Home/Companion Care • Community • Own home/family home • Assisted Living • Supervised Living Home and Community-Based Settings
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 16 §1915(i) State plan HCBS Approved: Supersedes:71 (By checking the following boxes the state assures that): 1. 俶There is an independent assessment of individuals determined to be eligible for the State plan HCBS benefit. The assessment meets federal requirements at 42 CFR §441.720. 2. 俶Based on the independent assessment, there is a person-centered service plan for each individual determined to be eligible for the State plan HCBS benefit. The person-centered service plan is developed using a person-centered service planning process in accordance with 42 CFR §441.725(a), and the written person-centered service plan meets federal requirements at 42 CFR §441.725(b). 3. 俶The person-centered service plan is reviewed, and revised upon reassessment of functional need as required under 42 CFR §441.720, at least every 12 months, when the individual’s circumstances or needs change significantly, and at the request of the individual. 4. Responsibility for Face-to-Face Assessment of an Individual’s Support Needs and Capabilities. There are educational/professional qualifications (that are reasonably related to performing assessments) of the individuals who will be responsible for conducting the independent assessment, including specific training in assessment of individuals with need for HCBS. (Specify qualifications): Person-Centered Planning & Service Delivery 1) Qualified Mental Health Professional -- a person who has demonstrated and documented competency in the work to be performed and: (A) has a bachelor's degree from an accredited college or university with a minimum number of hours that is equivalent to a major in psychology, social work, medicine, nursing, rehabilitation, counseling, sociology, human growth and development, physician assistant, gerontology, special education, educational psychology, early childhood education, or early childhood intervention (as determined by the LMHA or MCO in accordance with 26 TAC, Part 1, Chapter 301, Subchapter G §301.331 (relating to Competency and Credentialing)); (B) is a registered nurse; or (C) completes an alternative credentialing process identified by HHSC. or 2) Licensed Practitioner of the Healing Arts: (A) a physician; (B) a licensed professional counselor; (C) a licensed clinical social worker; (D) a psychologist; (E) an advanced practice registered nurse recognized by the Texas Board of Nursing as a clinical nurse specialist in psychiatry/mental health or nurse practitioner in psychiatry/mental health; or (F) A licensed marriage and family therapist. and Has received HHSC-approved training in evaluating individuals for HCBS-AMH.
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 17 §1915(i) State plan HCBS Approved: Supersedes 71 5. Responsibility for Development of Person-Centered Service Plan. There are qualifications (that are reasonably related to developing service plans) for persons responsible for the development of the individualized, person-centered service plan. (Specify qualifications): 6. Supporting the Participant in Development of Person-Centered Service Plan. Supports and information are made available to the participant (and/or the additional parties specified, as appropriate) to direct and be actively engaged in the person-centered service plan development process. (Specify: (a) the supports and information made available, and (b) the participant’s authority to determine who is included in the process): 7. Informed Choice of Providers. (Describe how participants are assisted in obtaining information about and selecting from among qualified providers of the 1915(i) services in the person-centered serviceplan): Individual providers of recovery management who develop the person-centered service plan must: x Have at least 2 years of experience working with people with severe mental illness; x Have a master’s degree in human services or a related field (the requirement to have a master’s degree may be waived by HHSC if HHSC determines that waiver is necessary to provide access to care to Medicaid recipients); x Demonstrate knowledge of issues affecting people with severe mental illness and community- based interventions/resources for this population; and x Complete HHSC-required training in the HCBS-AMH program. Individuals will be afforded the services of an independent Recovery Manager, trained and competent in person-centered planning who will support the individual in all aspects of their recovery process, including assisting the creation of the IRP, helping the individual gain access to needed services and other resources; making informed choices according to individual needs and preferences; resolving issues impeding recovery; and developing strategies/resources to promote recovery. The IRP addresses the individual’s personal preferences, choices, and goals. It is directed by the individual and involves the interdisciplinary team (IDT), which includes participants whom the individual has freely chosen including the individual, recovery manager, legally authorized representative, and others, , such as natural supports, advocates and service providers. The IRP is based on information from the independent needs-based assessment, which is conducted by HHSC staff or contractors. The individual and team identify the individual’s strengths, needs, preferences, and desired outcomes to determine the nature, amount, and scope of Medicaid and non- Medicaid services required. The resulting IRP incorporates the individual’s goals and preferences, including those related to community participation in the most integrated setting, employment, income and savings, health care and wellness, education, and others. The IRP also takes into account the participant’s social, treatment, and service history. Each individual will be afforded the services of an independent Recovery Manager. The Recovery Manager will support the individual in all aspects of their recovery process including assisting the individual in gaining access to needed services and other resources, making informed choice of services and providers according to individual needs and preferences, resolving issues impeding recovery, and developing strategies/resources to promote recovery. The HCBS-AMH Recovery Manager will inform the individual and IDT of qualified provider options when IRPs are developed and revised. Documentation regarding provider choice is included in the individual’s record and updates to that record.
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 18 §1915(i) State plan HCBS Approved: Supersedes:71 8. Process for Making Person-Centered Service Plan Subject to the Approval of the Medicaid Agency. (Describe the process by which the person-centered service plan is made subject to the approval of the Medicaid agency): The person-centered service plan (Individual Recovery Plan – IRP) will be developed by the individual’s recovery manager, with full participation of the individual and significant others in a person-centered planning process that is based on the individual’s preferences, needs, and personal goals. HHSC will review and authorize the IRPs. Individual plan data will include, at a minimum, the type, amount, and duration of services to be provided; effective dates of service; and individual goals. HHSC will collect and maintain individual recovery plan (IRP) data and provide aggregate reporting on utilization review findings. HHSC will use an electronic data system to collect clinical information and authorize service plans/requests. The HHSC Clinical Management for Behavioral Health Services (CMBHS) system will provide a platform for HHSC employees and providers to electronically submit data. The CMBHS system will interface with the MMIS to allow service authorization and claims payment. This system will ensure that authorizations for services are in place ensuring correct claims payment to certified Medicaid providers. Until the MMIS is modified, HHSC will authorize individual recovery plans and pay claims manually. All claims will be subject to final review and approval by the single state Medicaid agency. HHSC will perform first-level review of 100 percent of person-centered service plans, referred to as the Individual Recovery Plans (IRPs), consistent with operating procedures approved by HHSC. HHSC will collect and maintain aggregate performance data. In addition, HHSC will collect and maintain individual IRP data. Individual IRP data includes the IRPs, any supporting documentation, and claims/utilization records related to implementation of the IRPs. HHSC will retain final review and approval authority over the IRPs. Services must be planned for and provided in home and community-based settings and provided in the least restrictive manner possible. Individuals are free to participate in services on their IRP or refuse these services. Restraint is used only as last resort after less restrictive measures have been found to be ineffective or are judged unlikely to protect the individual or others from harm. Other forms of interventions that restrict participant movement, participant access to other individuals, locations or activities, restrict participant rights or employ other aversive methods to modify behavior are not allowable. Individuals must provide informed consent regarding the potential use of restrictive intervention. This potential use must be included on the individual’s safety plan on the IRP, which must also confirm that the individual understands his/her rights and how to report abuse, neglect, and exploitation. The use of restraints is prohibited except in a behavioral emergency. A behavioral emergency is a situation involving an individual who is behaving in a violent or self-destructive manner and in which preventive, de- escalative, or verbal techniques have been determined to be ineffective and it is immediately necessary to restrain the individual to prevent: • imminent probable death or substantial bodily harm to the individual because the individual is attempting to commit suicide or inflict serious bodily harm; or • imminent physical harm to others because of acts the individual is currently committing. Restrictive intervention is used for the shortest period possible and terminated as soon as the individual demonstrates safe behaviors. The use of any restrictive intervention must be reported to HHSC as a critical incident by the provider. All critical incidents are reviewed by HHSC. Direct staff shall: • Respect and preserve the rights of an individual during restrictive interventions; • Provide an environment that is protected and private from other individuals and that safeguards the personal dignity and well-being of an individual placed in restrictive interventions; • Ensure that undue physical discomfort, harm, or pain to the individual does not occur when initiating or using restrictive interventions; • Use only the amount of physical force that is reasonable and necessary to implement a particular restrictive intervention.
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 19 §1915(i) State plan HCBS Approved: Supersedes:71 The use of restrictive interventions is permissible on the provider’s property or for transportation of an individual only if implemented: • In accordance with state law regarding interventions in mental health services; • When less restrictive interventions (such as those listed in the individual’s safety plan) are determined ineffective to protect other individuals, the individual, staff members, or others from harm; • In connection with applicable evaluation and monitoring; • In accordance with any alternative strategies and special considerations documented in the IRP; • When the type or technique of restrictive intervention used is the least restrictive intervention that will be effective to protect the other individuals, the individual, staff members, or others from harm; and • Is discontinued at the earliest possible time. The HCBS-AMH provider must take into consideration information that could contraindicate or otherwise affect the use of personal restraint, including information obtained during the assessment. This information includes, but is not limited to: • Techniques, methods, or tools that would help the individual effectively cope with his or her environment; • Pre-existing medical conditions or any physical disabilities and limitations, including substance use disorders, that would place the individual at greater risk during restraint; • Any history of sexual or physical abuse that would place the individual at greater psychological risk during restraint; and • Any history that would contraindicate restraint. An individual held in restraint shall be under continuous direct observation. The HCBS-AMH provider shall ensure adequate respiration and circulation during restraint. The use of planned restrictive interventions is reflected on the individuals IRP, which is submitted to HHSC for approval. The use of physical restraints must be documented as a critical incident by the HCBS-AMH provider and reported to HHSC. Unauthorized use of restrictive interventions will be detected by record review and through complaints. The oversight of personal restraint for HCBS-AMH providers is accomplished through the quarterly risk assessment conducted by HHSC. The HCBS-AMH provider shall record the following information in the clinical record: • The circumstances leading to the use of personal restraint; • The specific behavior necessitating the restraint and the behavior required for release; • Less restrictive interventions that were tried before restraint began; • The names of the direct service staff who implemented the restraint; • The date and time the restraint began and ended; and • The individual’s response. The recovery manager shall convene the individual’s IDT and document alternative strategies for dealing with behaviors in each of the following circumstances and update the IRP and safety plan accordingly: • In any case in which behaviors have necessitated the use of restrictive interventions for the same individual more than two times during any 30-day period; and • When two or more separate episodes of restrictive interventions of any duration have occurred within the same 12 hour period. The use of chemical restraints and mechanical restraints by HCBS-AMH providers is prohibited. The use of seclusion is prohibited. Restraint shall not be used: • As a means of discipline, retaliation, punishment, or coercion; • For the purpose of convenience of staff members or other individuals; or • As a substitute for effective treatment or habilitation. Restraints that do any of the following are prohibited: • Obstruct the individual's airway, including a procedure that places anything in, on, or over the individual's
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 20 §1915(i) State plan HCBS Approved: Supersedes:71 mouth or nose; • Impair the individual's breathing, including applying pressure to the individual's torso or neck; • Restrict circulation; • Secure an individual to a stationary object; • Cause pain to restrict an individual's movement (pressure points or joint locks); • Inhibit, reduce, or hinder the individual's ability to communicate; and • Are protective or supportive devices that are not easily removable by the individual without assistance. A prone or supine hold shall not be used during a personal restraint. Should an individual become prone or supine during a restraint, then any provider involved in administering the restraint shall immediately transition the individual to a side lying or other appropriate position. Providers shall ensure that direct service members are informed of their roles and responsibilities and are trained and demonstrate competence accordingly. Before assuming job duties involving direct care responsibilities, and at least annually thereafter, direct service staff must receive training and demonstrate competence in at least the following knowledge and applied skills that shall be specific and appropriate to the target population of HCBS-AMH: • The use of restraint, including how to perform the restraint; • Identifying the causes of aggressive or threatening behaviors of individuals who need mental health services, including behavior that may be related to an individual's non-psychiatric medical condition; • Identifying underlying cognitive functioning and medical, physical, and emotional conditions; • Identifying medications and their potential effects; • Identifying how age, weight, cognitive functioning, developmental level or functioning, gender, culture, ethnicity, and elements of trauma-informed care, including history of abuse or trauma and prior experience with restraint or seclusion, may influence behavioral emergencies and affect the individual's response to physical contact and behavioral interventions; • Explaining how the psychological consequences of restraint and the behavior of staff members can affect an individual's behavior, and how the behavior of individuals can affect a staff member; • Applying knowledge and effective use of communication strategies and a range of early intervention, de- escalation, mediation, problem-solving, and other non-physical interventions, such as clinical timeout and quiet time; and Recognizing and appropriately responding to signs of physical distress in individuals who are restrained or secluded, including the risks of asphyxiation, aspiration, and trauma. Before any direct service staff may initiate any restraint, direct service staff shall receive training and demonstrate competence in: • Safe and appropriate initiation and use of restraint as a last resort in a behavioral emergency; • Safe and appropriate initiation and application, and use of personal restraint as a last resort in a behavioral emergency; • Safe and appropriate initiation and application, and use of restraint as a last resort in a behavioral emergency or as a protective or supportive device. • Management of emergency medical conditions in accordance with the provider's policies and procedures and other applicable requirements for: o obtaining emergency medical assistance; and o obtaining training in and using techniques for cardiopulmonary respiration and removal of airway obstructions. Before assuming job duties, and at least annually thereafter, a registered nurse or a physician assistant who is authorized to: • Perform assessments of individuals who are in restraint shall receive training, which shall include a demonstration of competence in: o monitoring cardiac and respiratory status and interpreting their relevance to the physical safety of the individual in restraint; o recognizing and responding to nutritional and hydration needs; o checking circulation in, and range of motion of, the extremities; o providing for hygiene and elimination; o identifying and responding to physical and psychological status and comfort, including signs of
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 21 §1915(i) State plan HCBS Approved: Supersedes:71 distress; o assisting individuals in de-escalating, including through identification and removal of stimuli, that meet the criteria for a behavioral emergency if known; o recognizing when continuation of restraint is no longer justified by a behavioral emergency; and o recognizing when to contact emergency medical services to evaluate and/or treat an individual for an emergency medical condition. • Conduct evaluations of individuals, including face-to-face evaluations relating to initiation of restraint or in a behavioral emergency of individuals who are in restraint, shall receive training, which shall include a demonstration of competence in: o identifying restraints that are permitted by the provider and by applicable law; o identifying stimuli that trigger behaviors; o identifying medical contraindications to restraint; o recognizing psychological factors to be considered when using restraint, such as sexual abuse, physical abuse, neglect, and trauma. Before assuming job duties, and at least annually thereafter, providers who are authorized to monitor, under the supervision of a registered nurse, individuals during restraint shall receive training, which shall include a demonstration of competence in: • Monitoring respiratory status; • Recognizing nutritional and hydration needs; • Checking circulation in, and range of motion of, the extremities; • Providing for hygiene and elimination; • Addressing physical and psychological status and comfort, including signs of distress; • Assisting individuals in de-escalating, including through identification and removal of stimuli, if known. • Recognizing when continuation of restraint is no longer justified by a behavioral emergency; and • Recognizing when to contact a registered nurse. HHSC is responsible for overseeing the use of restrictive interventions with individuals enrolled in HCBS- AMH. The use of restrictive interventions, including personal restraints, are reported as critical incidents and managed as part of the contract oversight process by HHSC. HHSC’s oversight of the use of personal restraints by HCBS-AMH providers is accomplished through annual risk assessment conducted by HHSC. Unauthorized use of restraint will be detected by record review, site review, and through complaints. HHSC is responsible for overseeing the reporting of and response to critical incidents that affect individuals enrolled in HCBS-AMH. Critical incidents are managed as part of the contract oversight process by HHSC. The State utilizes Critical Event or Incident Reporting and Management Processes that enable the State to collect information on sentinel events that occur. Critical incidents are situations that threaten the health and safety of the individual or the community or pose a significant change in the individual’s status or environment. HCBS- AMH providers shall be responsible for implementing a procedure which ensures the reporting of all critical incidences. Incidences may include, but are not limited to, the following: • Abuse, neglect, or exploitation of an HCBS-AMH participant; • Hospital admission and discharge; • Nursing home placement other than for the provision of respite; • Incarceration; • Restraint of an HCBS-AMH participant; • A slip or fall, medication error, or medical complication; or • Incidents caused by the individual such as verbal and/or physical abuse of providers or other participants, destruction or damage of property, contraband, and member self-abuse; • Eviction from primary residence; • The individual poses an immediate health or safety risk to self or others; or • Serious injury or death. In the case of critical incidents, HCBS-AMH providers are expected to take immediate action to resolve, when feasible, and to report to the appropriate state and/or law enforcement entities. Providers shall submit to HHSC the Critical Incident Report Form within 72 hours of notification of outcome of the incident with any updated information. During HHSC site review of HCBS-AMH providers, HHSC reviews critical incident reports to ensure compliance.
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 22 §1915(i) State plan HCBS Approved: Supersedes:71 The HCBS-AMH provider will cooperate with and assist HHSC, HHSC, and any state or federal agency charged with the duty of identifying, investigating, sanctioning or prosecuting suspected fraud and abuse, including the Office of Inspector General at HHSC. The Department of Family and Protective Services (DFPS) is responsible for investigating abuse, neglect and exploitation and providing services to adults who are over age 65 or have a disabling condition such as a mental, physical, or developmental disability that substantially impairs their ability to live on their own or provide for their own self-care or protection. The Department of Family and Protective Services (DFPS) will provide HHSC copies of each investigation of ANE allegations involving an individual enrolled in the HCBS-AMH. Regardless of the investigation findings, HHSC reviews each investigative report. HHSC regulates assisted living facilities and associated complaints of abuse by providers of HCBS-AMH services in assisted living facilities and HCBS-AMH providers of respite in nursing home settings. HHSC notifies individuals of his/her rights prior to enrollment into the HCBS-AMH Program. HHSC verifies notification of the individual of his/her rights through the individual or LAR’s signature on the Notification of Participant Rights Form as part of the enrollment process. The Notification of Participant Rights Form: • Informs the individual of the contact information for DFPS and the Office of the Ombudsman; • Informs the individual of his/her right to a Fair Hearing regarding the HCBS-AMH Program; and • Informs the individual of the process for reporting allegations of ANE and the toll free number for DFPS. HCBS-AMH providers and recovery managers must also provide information to the individual and LAR regarding the participant’s rights and how the participant or LAR can notify appropriate authorities or entities when the participant has experienced ANE. This information must be provided by recovery managers and providers when the individual and/or LAR request it, and when the provider or recovery manager identify a need to provide the information. The name, telephone number, and mailing address of the HCBS-AMH provider’s rights protection officer must be prominently posted in every area that is frequented by HCBS-AMH participants. Individuals desiring to contact the rights protection officer must be allowed access to the HCBS-AMH Provider’s telephones to do so. The method used to communicate the information will be designed for effective communication, tailored to meet each person’s ability to comprehend, and responsive to any visual or hearing impairment. Oral communications of rights will be documented on the Notification of Participant Rights Form bearing the date and signatures of the individual enrolled in HCBS-AMH and/or LAR and the staff person who explained the rights. The Notification of Participant Rights Form will be filed in the individual’s clinical record. HCBS-AMH Providers are responsible for monitoring participant medication regimens, including the administration of medications to individuals enrolled in HCBS-AMH who cannot self-administer and/or the oversight of individuals enrolled in HCBS-AMH who self-administer medications. • At least annually, the HCBS-AMH Provider must assure that staff administering medications be qualified under their scope of practice. • The HCBS-AMH provider must assure that staff who have been delegated the authority to administer medications or delegated oversight of individuals who self-administer medications receive instruction in medication administration and monitoring from a practitioner with delegation authority before assuming their duties and as indicated by changes in the client’s condition or medication regimen. The staff delegated to administer the medications will be trained and have knowledge of each medication, what it is prescribed for, and the adverse reactions and side effects. • The HCBS-AMH provider must monitor staff who have been delegated authority to administer medications or delegated oversight of individuals who self-administer medications. The frequency and monitoring is based on the individual’s condition, medication regimen, and changes to the medication regimen. • If applicable, the LAR must sign an authorization for the HCBS-AMH provider to administer each medication according to label directions. • The medication must be in the original container labeled with the expiration date and the individual’s full name.
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 23 §1915(i) State plan HCBS Approved: Supersedes:71 9. Maintenance of Person-Centered Service Plan Forms. Written copies or electronic facsimiles of service plans are maintained for a minimum period of 3 years as required by 45 CFR §74.53. Service plans are maintained by the following (check each that applies): : Medicaid agency
Operating agency : Case manager
Other (specify): • The HCBS-AMH provider must administer the medication according to the label directions or as amended by a physician. • The HCBS-AMH provider must administer the medication only to the individual for whom it is intended. • The HCBS-AMH provider must not administer the medication after its expiration date. • If applicable, the HCBS-AMH provider may provide non-prescription medications if the HCBS-AMH provider obtains LAR consent prior to administration of the medication. Consent may be given over the phone and documented as such by the HCBS-AMH provider. • At least quarterly, or more frequently if indicated by the individual’s condition, medication regimen or changes to the regimen, HCBS-AMH providers shall review medication administration records to ensure that medications are correctly administered. HHSC includes medication management review as part of its annual review of contracted HCBS-AMH providers. HHSC is responsible for monitoring the performance of providers administering medications to the individual. HHSC enforces requirements through annual assessment and review of critical incidents.
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 24 §1915(i) State plan HCBS Approved: Supersedes:71 1. State plan HCBS. (Complete the following table for each service. Copy table as needed): Service Specifications (Specify a service title for the HCBS listed in Attachment 4.19-B that the state plans to cover): Service Title: Transition Assistance Services (TAS) Service Definition (Scope): TAS pays set-up expenses for individuals transitioning from institutions into community settings. Allowable expenses are those necessary to enable individuals to establish basic households and may include: security deposits for leases on apartments or homes; essential household furnishings and expenses required to occupy and use a community domicile, including furniture, window coverings, food preparation items, and bed and bath linens; set-up fees or deposits for utility or service access, including telephone, electricity, gas, and water; and services necessary for an individual's health and welfare, such as pest eradication and one-time cleaning prior to occupancy. TAS may also include services necessary for an individual's health and welfare, such as pest eradication and one- time cleaning prior to occupancy, and activities to assess need, arrange for, and procure needed resources (limited to up to 180 consecutive days prior to discharge). Providers may only bill Medicaid for TAS on or after the date that the individual is enrolled in the state plan benefit, on or after the date of discharge from the facility, and pursuant to the IRP. Room and board are not allowable TAS expenses. TAS are furnished only to the extent that the expense is reasonable and necessary, as determined through the individual recovery plan development process, and is clearly identified in the individual recovery plan. The IRP must document that individuals are unable to meet such expenses or the services cannot be obtained from other sources. TAS does not include: monthly rental or mortgage expenses, food, regular utility charges, major household appliances, or items that are intended for purely recreational purposes. TAS excludes shared expenses, such as furniture and appliances, covered under provider owned or operated residential options. Additional needs-based criteria for receiving the service, if applicable (specify): Specify limits (if any) on the amount, duration, or scope of this service. Per 42 CFR Section 440.240, services available to any categorically needy recipient cannot be less in amount, duration and scope than those services available to a medically needy recipient, and services must be equal for any individual within a group. States must also separately address standard state plan service questions related to sufficiency of services. (Choose each that applies): 俶䢢Categorically needy (specify limits): There is a $2,500 cost cap per participant for the transition event into his/her own home, including settings with supported home living and companion care arrangements. Individuals transitioning to their own home (not a provider-owned or operated setting) have a need to purchase and arrange for essential household furnishings and expenses required to occupy and use a community domicile. There is a $1,000 cost cap per participant for the transition event into a host home, supervised living, or assisted living arrangement. This cost cap reflects that, while the individual will need items to personalize their living space, other items such as furniture are provided by the residential setting. Medically needy (specify limits): N/A Provider Qualifications (For each type of provider. Copy rows as needed): Provider Type (Specify): License (Specify): Certification (Specify): Other Standard (Specify): Services
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 25 §1915(i) State plan HCBS Approved: Supersedes:71 HCBS Provider Agency that meets the minimum eligibility and standards for HCBS-AMH provider enrollment. HCBS provider agency enrolled and contracted with HHSC to provide HCBS services, which employs or contracts with a provider of TAS services. The TAS provider must comply with the requirements for delivery of transition assistance services, which include requirements such as allowable purchases, cost limits, and time frames for delivery. TAS providers must demonstrate knowledge of, and history in, successfully serving individuals who require home and community-based services. Before entering into a provider agreement with the provider agency, HHSC verifies the providers’ compliance with these qualifications through a credentialing process. Contracted providers are obligated to verify on an ongoing basis that these qualifications are achieved, maintained, and documented. HHSC will conduct annual review to verify these requirements continue to be met after the provider and HHSC enter into an agreement. Individual providers of TAS must be 18 years of age or older, pass criminal background check, demonstrate knowledge and/or experience in managing transitions to home and community-based settings. Verification of Provider Qualifications (For each provider type listed above. Copy rows as needed): Provider Type (Specify): Entity Responsible for Verification (Specify): Frequency of Verification (Specify): HCBS Provider Agency that meets the minimum eligibility and standards for HCBS-AMH provider enrollment. HHSC Annual Service Delivery Method. (Check each that applies): Participant-directed 俶䢢Provider managed Service Specifications (Specify a service title for the HCBS listed in Attachment 4.19-B that the state plans to cover): Service Title: HCBS Psychosocial Rehabilitation Services Service Definition (Scope): HCBS Psychosocial Rehabilitation services are evidence-based or evidence-informed interventions which support the individual’s recovery by helping the individual develop, refine, and/or maintain the skills needed to function successfully in the community to the fullest extent possible. Skills include, but are not limited to: illness/recovery management, self-care, activities of daily living, and instrumental activities of daily living. The modality(ies) used must be approved by HHSC. A variety of evidence-based practices may be used as appropriate to individual needs, interests and goals. Activities included must be intended to achieve the identified goals or objectives as set forth in the individual’s IRP. Rehabilitative services are face-to-face interventions with the individual present. Services may be provided individually or in a group setting. The provider must incorporate research-based approaches pertinent to the needs of the target population.
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 26 §1915(i) State plan HCBS Approved: Supersedes:71 Approaches used must be approved by HHSC. Examples of specific research-based approaches that could be used for various sub-populations of clients include, but are not limited to: Cognitive Adaptation Training (CAT): An evidence-based practice which provides assistance and environmental modifications to help individuals establish daily routines, organize their environment, and build social skills, with the ultimate goal of increasing independence. CAT compensates for cognitive deficits from mental illness (such as psychomotor speed, attention, and memory) by providing visual clues, signage, and organization of the individual’s environment, which results in increased independent functioning. CAT improves the individual’s ability to perform activities of daily living such as dressing, hygiene, social skills and communication, medication management, toileting, leisure skills, and transportation. Illness Management and Recovery (IMR): IMR gives individuals information about mental illnesses and coping skills to help them manage their illnesses, develop goals, and make informed decisions about their treatment. IMR practitioners help individuals define recovery for themselves and identify personally meaningful recovery goals. In IMR, education about mental illnesses is the foundation of informed decision-making. Practitioners help individuals build social networks and engage supporters in activities that promote recovery. Individuals learn to identify early warning signs and plan steps that they can take to prevent relapses. They also learn strategies to help them manage their symptoms, cope with stress, and significantly improve their lives. Seeking Safety: Present-focused therapy to help people attain safety from trauma, post-traumatic stress disorder, and substance abuse. This therapy was developed by Lisa M. Najavits at Harvard Medical School/McLean Hospital in 1992. Rehabilitation services are provided by practitioners working under the direction of the HCBS-AMH Provider Agency and supervision of clinicians who are credentialed or qualified in the specific evidence-based practices. Additional needs-based criteria for receiving the service, if applicable (specify): Specify limits (if any) on the amount, duration, or scope of this service. Per 42 CFR Section 440.240, services available to any categorically needy recipient cannot be less in amount, duration and scope than those services available to a medically needy recipient, and services must be equal for any individual within a group. States must also separately address standard state plan service questions related to sufficiency of services. (Choose each that applies): 俶䢢 Categorically needy (specify limits): HCBS-AMH rehabilitation services cannot be delivered at the same time as State Plan mental health rehabilitative services. Individuals will receive State Plan mental health rehabilitative services if the individual so desires and those services are appropriate for the individual. Services are subject to prior approval by HHSC and may be subject to periodic reviews to ensure fidelity with evidence-based practice. Service plans for HCBS Psychosocial Rehabilitation must be developed with a practitioner credentialed in the evidence-based practices (EBP). The activities included under HCBS Psychosocial Rehabilitation services must be intended to achieve identified IRP goals or objectives and must be reviewed at least annually with the individual and significant others as part of the IRP process to determine whether the services are meeting related IRP goals and objectives, and may be adjusted as needed to reflect the individual’s needs, preferences and progress. As outlined in the IRP, services may be provided at an office of the provider, in the community, or in the individual’s place of residence. Rehabilitative services are not intended to substitute for personal assistance services. Medically needy (specify limits): N/A Provider Qualifications (For each type of provider. Copy rows as needed): Provider Type (Specify): License (Specify): Certification (Specify): Other Standard (Specify):
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 27 §1915(i) State plan HCBS Approved: Supersedes:71 HCBS Provider Agency that meets the minimum eligibility and standards for HCBS- AMH provider enrollment. HCBS provider agency enrolled and contracted with HHSC to provide HCBS- AMH services, which employs or has a contract with the HCBS Psychosocial Rehabilitation practitioner. Before entering into a provider agreement with the provider agency, HHSC verifies the providers’ compliance with these qualifications through a credentialing process. Contracted providers are obligated to verify on an ongoing basis that these qualifications are achieved, maintained, and documented in personnel files. HHSC will conduct annual review to verify these requirements continue to be met after the provider and HHSC enter into an agreement. Individual providers must be qualified and demonstrate competency and fidelity to the evidence-based practices (EBPs) used. Individual providers must have the level of education and experience required by the evidence-based modality employed. An individual provider must, at a minimum, have a bachelor’s degree in psychology or a related field, HHSC-approved training and/or certification in the evidence-based practice(s) employed and must be supervised by a licensed clinician trained and competent in the EBP. Verification of Provider Qualifications (For each provider type listed above. Copy rows as needed): Provider Type (Specify): Entity Responsible for Verification (Specify): Frequency of Verification (Specify): HCBS Provider Agency that meets the minimum eligibility and standards for HCBS- AMH provider enrollment. HHSC Annual Service Delivery Method. (Check each that applies): Participant-directed 俶䢢Provider managed Service Specifications (Specify a service title for the HCBS listed in Attachment 4.19-B that the state plans to cover): Service Title: Adaptive aids Service Definition (Scope):
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 28 §1915(i) State plan HCBS Approved: Supersedes:71 Specialized equipment and supplies including devices, controls and appliances that enable individuals to increase their abilities to perform activities of daily living; to perceive, control, or communicate with the environment in which they live; allow the individual to integrate more fully into the community; or to ensure the health, welfare and safety of the individual. Adaptive aids include vehicle adaptations or modifications, environmental adaptations, and aids for daily living, such as reachers, adapted utensils, certain types of lifts, pill keepers, reminder devices, signs, calendars, planners, and storage devices. Vehicle adaptations or modifications that are specified on the IRP may be made to a vehicle that is not owned by the provider and is the individual’s primary means of transportation in order to accommodate the identified needs of the individual. Vehicle adaptations or modifications do not include the following: (1) adaptations or improvements to the vehicle that are of general utility, and are not of direct medical or remedial benefit to the individual; (2) purchase or lease of a vehicle; and (3) regularly scheduled upkeep and maintenance of a vehicle, except upkeep and maintenance of the modifications. Adaptive aids also include service animals and items associated with equipping, training, and maintaining the health and safety of a service animal. (These items include veterinary care; travel benefits associated with obtaining and training an animal; and the provision, maintenance, and replacement of items and supplies required for the animal to perform the tasks necessary to assist individuals. The cost effectiveness of medical interventions outside of routine veterinary care is to be determined on an individual basis.) Other items may be included if specifically required to realize a goal specified in the IRP and prior approved by HHSC. Items reimbursed are in addition to any supports furnished under the State Plan and do not include those items which are not of direct benefit to the individual. All items must meet applicable standards of manufacture, design, and installation. Service animals must be provided in accordance with the IRP and documented as necessary for the individual to remain in the community. This 1915(i) service is only provided to individuals age 21 and over. All medically necessary adaptive aid services for children under age 21 are covered in the state plan pursuant to the EPSDT benefit. Additional needs-based criteria for receiving the service, if applicable (specify): Individual items costing over $500.00 must be recommended in writing by a licensed practitioner of the healing arts (Physician, Advanced Practice Registered Nurse, Psychologist, Licensed Professional Counselor, Licensed Clinical Social Worker or Licensed Marriage and Family Therapist qualified to assess the individual’s need for the specific adaptive aid and be approved by HHSC. Specify limits (if any) on the amount, duration, or scope of this service. Per 42 CFR Section 440.240, services available to any categorically needy recipient cannot be less in amount, duration and scope than those services available to a medically needy recipient, and services must be equal for any individual within a group. States must also separately address standard state plan service questions related to sufficiency of services. (Choose each that applies): 俶䢢 Categorically needy (specify limits): The annual cap is $10,000 per individual, per year. Should an individual require adaptive aids after the cost limit has been reached, the recovery manager assists the individual/family to access any other resources or alternate funding sources. Adaptive aids are available only after benefits available through Medicare, other Medicaid benefits, or other third party resources have been documented as exhausted. Adaptive aids are limited to those categories specified in the state plan amendment. Medically needy (specify limits): N/A Provider Qualifications (For each type of provider. Copy rows as needed): Provider Type (Specify): License (Specify): Certification (Specify): Other Standard (Specify):
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 29 §1915(i) State plan HCBS Approved: Supersedes:71 HCBS Provider Agency that meets the minimum eligibility and standards for HCBS- AMH provider enrollment. HCBS provider agency enrolled and contracted with HHSC to provide HCBS services, which employs or has contracts with adaptive aid providers. Before entering into a provider agreement with the provider agency, HHSC verifies the providers’ compliance with these qualifications through a credentialing process. Contracted providers are obligated to verify on an ongoing basis that these qualifications are achieved, maintained, and documented in personnel files. HHSC will conduct annual review to verify these requirements continue to be met after the provider and HHSC enter into an agreement. Adaptive aid providers and their employees must comply with all applicable laws and regulations for the provision of adaptive aids. Verification of Provider Qualifications (For each provider type listed above. Copy rows as needed): Provider Type (Specify): Entity Responsible for Verification (Specify): Frequency of Verification (Specify): HCBS Provider Agency that meets the minimum eligibility and standards for HCBS- AMH provider enrollment. HHSC Annual Service Delivery Method. (Check each that applies): Participant-directed 俶䢢Provider managed Service Specifications (Specify a service title for the HCBS listed in Attachment 4.19-B that the state plans to cover): Service Title: Employment Services Service Definition (Scope): Employment services help people with severe mental illness work at regular jobs of their choosing and to achieve goals meaningful to them, such as increasing their economic security. Services must follow evidence- based or evidence-informed practices approved by HHSC. Employment services: x focus on the individual’s strengths and preferences; x promote recovery and wellness by enabling individuals to engage in work which is meaningful to them and compensated at a level equal to or greater than individuals without severe mental illness or other disabilities (competitive employment); x collaborate with and do not supplant existing resources, such as state vocational rehabilitation programs available to the individual; x use a multidisciplinary team approach; x are individualized and extended as needed to assist the individual attain and maintain meaningful work; x are provided based on individual preference and choice without exclusions based on readiness, diagnoses, symptoms, substance use history, psychiatric hospitalizations, level of disability, or legal system involvement; x are coordinated with mental health services provided to the individual, such as rehabilitation; x help individuals obtain personalized, understandable, and accurate information about their Social Security, Medicaid, and other government entitlements in relation to work;
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 30 §1915(i) State plan HCBS Approved: Supersedes 71: x help individuals obtain jobs directly, rather than mandating lengthy pre-employment assessment, training, and counseling; x include systematic job development based on individuals’ interests, developing relationships with local employers by making systematic contacts; and x provide time-unlimited and individualized support for as long the individual wants and needs support. Supported Employment Supported Employment provides individualized services to sustain individuals in paid jobs in regular work settings, who, because of disability, require support to be self-employed, work from home, or perform in a work setting at which individuals without disabilities are employed. Supported Employment includes adaptations, assistance, and training essential for individuals to sustain paid employment at or above the minimum wages and benefits provided to non-disabled workers performing similar jobs. Transporting an individual to support the individual to be self-employed, work from home, or perform in a community-based work setting is billable within the service. Components include: x on-the-job training and skills development; x assisting the individual with development of natural supports in the workplace; x helping individuals attend school and providing academic supports, when that is their preference; x coordinating with employers or employees, coworkers and customers, as necessary. (Note: Coordinating with employers and other employees is done only if the individual prefers to have her or his mental illness disclosed and gives permission); x providing work incentives planning prior to or during the process of job placement. Work incentives planning involves helping the person review her or his options for working (number of hours per week, etc.), given the hourly pay the person is being offered, or is likely to be offered, the person's current income needs, and the rules concerning how SSA benefits, medical benefits, medical subsidies, and other subsidies (housing, food stamps, etc.) change based on income from paid employment. Work incentives planning allows individuals to make informed decisions about how many hours per week to work, as well as their preferred timing in moving from part-time to full-time work. Individuals also are given information and assistance about reporting earnings to various sources of entitlements/benefits; x assisting individuals in making informed decisions about whether to disclose their mental illness condition to employers and co-workers; and x providing follow-along services for as long as the individual needs and desires them to help the individual maintain employment. Follow-along may include periodic reminders of effective workplace practices and reinforcement of skills. Employment Assistance Employment Assistance helps the individual locate and maintain paid employment in the community and may include activities on behalf of the individual to assist in maintaining employment. Components include: x identifying an individual’s employment preferences, job skills, and requirements for a work setting and work conditions; x engaging the individual in identifying a career direction and developing a plan for achieving competitive, integrated employment at or above the state’s minimum wage. The outcome of this activity is documentation of the individual’s stated career objective and a career plan used to guide individual employment assistance; x providing support to establish or maintain home-based or self-employment, when identified as a goal by the individual; x locating prospective employers offering employment compatible with the individual’s identified preferences, skills, and requirements; x contacting a prospective employer on behalf of an individual and negotiating the individual’s job development/employment; x developing customized employment options with the individual to meet the individual’s needs and preferences; and x transporting the individual to help the individual locate paid employment in the community. Additional needs-based criteria for receiving the service, if applicable (specify):
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 31 §1915(i) State plan HCBS Approved: Supersedes:71 Specify limits (if any) on the amount, duration, or scope of this service. Per 42 CFR Section 440.240, services available to any categorically needy recipient cannot be less in amount, duration and scope than those services available to a medically needy recipient, and services must be equal for any individual within a group. States must also separately address standard state plan service questions related to sufficiency of services. (Choose each that applies): 俶䢢 Categorically needy (specify limits): Services do not include payment for the supervisory activities rendered as a normal part of the business setting. Services do not include payment for supervision, training, support, and adaptations typically available to other non-disabled workers filling similar positions in the business. Services do not include adaptations, assistance, and training used to meet an employer’s responsibility to fulfill requirements for reasonable accommodations under the Americans with Disabilities Act. Transportation to and from the work site may be a component of - and the cost of this transportation may be included in - the rate paid to providers, unless the individual can access public transportation or has other means of transportation available to them. If public transportation is available, then it should be utilized by the individual, if at all possible. Employment Services may be used for an individual to gain work-related experience considered crucial for job, placement (e.g., unpaid internship), only if such experience is vital to the person to achieve his or her vocational goal. Documentation must be maintained for each individual receiving this service that the service is not available under a program funded under Section 110 of the Rehabilitation Act of 1973, relating to vocational rehabilitation services, or the Individuals with Disabilities Education Act (20 U.S.C. 1401 et seq.), relating to special education. Services may not be for job placements paying below minimum wage. Services must be delivered in a manner that supports and respects the individual’s communication needs including translation services, assistance with, and use of communication devices. Services may not be provided on the same day and at the same time as services that contain elements integral to the delivery of Employment Services (e.g., rehabilitation). Services must be provided in regular integrated settings and do not include sheltered work or other types of vocational services in specialized facilities, or incentive payments, subsidies, or unrelated vocational training expenses such as the following: • Incentive payments made to an employer to encourage hiring the individual; • Payments that are passed through to the individual; o Payments for supervision, training, support and adaptations typically available to other workers without disabilities filling similar positions in the business; or o Payments used to defray the expenses associated with starting up or operating a business. The documentation of employment services must be available to HHSC and to the Recovery Manager for monitoring at all times on an ongoing basis. The Recovery Manager will monitor on a quarterly basis to see if the objectives and outcomes are being met. Medically needy (specify limits): N/A Provider Qualifications (For each type of provider. Copy rows as needed): Provider Type (Specify): License (Specify): Certification (Specify): Other Standard (Specify): HCBS Provider agency that meets the minimum eligibility and standards for HCBS- AMH provider enrollment HCBS provider agency enrolled and contracted with HHSC to provide HCBS services, which employs or has agreements with employment practitioners with training/certification in evidence-based or evidence-informed employment services. The individual provider of employment
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 32 §1915(i) State plan HCBS Approved: Supersedes:71 services must be at least 18 years of age and meet one of the following qualifications: • have a bachelor's degree in rehabilitation, business, marketing, or a related human services field, and one year's paid or unpaid experience providing employment services to people with disabilities; • have an associate's degree in rehabilitation, business, marketing, or a related human services field, and two years' paid or unpaid experience providing employment services to people with disabilities; or • have a high school diploma or Certificate of High School Equivalency (GED credentials), and three years' paid or unpaid experience providing employment services to people with disabilities. The individual provider must complete training required by HHSC. Before entering into a provider agreement with the provider agency, HHSC verifies the providers’ compliance with these qualifications through a credentialing process. Contracted providers are obligated to verify on an ongoing basis that these qualifications are achieved, maintained, and documented in personnel files. HHSC will conduct annual review to verify these requirements continue to be met after the provider and HHSC enter into an agreement. Verification of Provider Qualifications (For each provider type listed above. Copy rows as needed): Provider Type (Specify): Entity Responsible for Verification (Specify): Frequency of Verification (Specify): HCBS Provider agency that meets the minimum eligibility and standards for HCBS- AMH provider enrollment. HHSC Annual Service Delivery Method. (Check each that applies): Participant-directed 俶䢢Provider managed Service Specifications (Specify a service title for the HCBS listed in Attachment 4.19-B that the state plans to cover): Service Title: Transportation Service Definition (Scope): Transportation is offered in order to enable individuals served to gain access to services, activities, and resources, as specified in the IRP. This service is offered in addition to medical transportation required under 42 C.F.R.§ 431.53 and transportation services under the State Plan, defined at 42 C.F.R. § 440.170(a) (if applicable), and will not replace them. Transportation services are offered in accordance with the individual's recovery plan. Whenever possible, family,
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 33 §1915(i) State plan HCBS Approved: Supersedes:71SDJH neighbors, friends, or community agencies that can provide this service without charge will be utilized. This service does not duplicate transportation provided as part of other services or under the State Plan medical transportation benefit. HCBS-AMH Transportation Services are for non-medical transportation needs related to goals identified on the IRP and are mutually exclusive of State Plan medical transportation services. Contracted providers are required to provide and document service provision of HCBS-AMH in accordance with program policies and procedures and billing guidelines. HCBS-AMH documentation requirements for HCBS-AMH Transportation include date of contact; mileage log with start and stop time; printed name of service provider; location of origination and destination; and signature and credentials of service provider. Documentation must support that claims for HCBS-AMH transportation are not duplicative or inclusive of transportation provided as part of another service, including other state plan transportation benefits. • System edits will be in place to prevent duplicative billing. • All Medicaid transportation services will be coordinated by the individual’s recovery manager and the relevant full-risk broker or managed transportation organization in the client’s area. • The state Medicaid authority has final authority over approval of claims. • The state will perform periodic review of claims data to check for duplicative claims. • Where duplicative claims are found, the State will recoup claims payment. HCBS-AMH Providers and direct service staff may not bill for Transportation Services when the transportation is related to or a part of another HCBS-AMH service such as Supported Home Living or Employment Services. Transportation activities associated with Supported Home Living and Employment Services shall be billed in accordance with the requirements of those services, respectively. This 1915(i) service is only provided to individuals age 21 and over. All medically necessary non-emergency medical transportation services for children under age 21 are covered in the state plan pursuant to the EPSDT benefit. Additional needs-based criteria for receiving the service, if applicable (specify): Specify limits (if any) on the amount, duration, or scope of this service. Per 42 CFR Section 440.240, services available to any categorically needy recipient cannot be less in amount, duration and scope than those services available to a medically needy recipient, and services must be equal for any individual within a group. States must also separately address standard state plan service questions related to sufficiency of services. (Choose each that applies): 俶䢢 Categorically needy (specify limits): There is a limit of $2000 per individual per year for this service. Medically needy (specify limits): N/A Provider Qualifications (For each type of provider. Copy rows as needed): Provider Type (Specify): License (Specify): Certification (Specify): Other Standard (Specify): HCBS provider agency that meets the minimum eligibility and standards for HCBS- AMH provider enrollment. HCBS provider agency enrolled and contracted with HHSC to provide HCBS services, which employs or contracts with transportation vendors. Individual transportation providers must be 18 years of age or older, pass a criminal background check, and have a valid driver's license and proof of insurance. Clients may also use specialized transport,
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 34 §1915(i) State plan HCBS Approved: Supersedes:71 buses, or taxis. Verification of Provider Qualifications (For each provider type listed above. Copy rows as needed): Provider Type (Specify): Entity Responsible for Verification (Specify): Frequency of Verification (Specify): Transportation HHSC Annual Service Delivery Method. (Check each that applies): Participant-directed 俶䢢Provider managed Service Specifications (Specify a service title for the HCBS listed in Attachment 4.19-B that the state plans to cover): Service Title: Community Psychiatric Supports and Treatment (CPST) Service Definition (Scope): CPST are goal-directed supports and solution-focused interventions intended to achieve identified goals or objectives as set forth in the individual’s IRP. CPST is a face-to-face intervention with the individual present; however, family or other persons significant to the individual may also be involved. This service may include the following components: Assist the individual and family members or other collaterals to identify strategies or treatment options associated with the individual’s mental illness and/or substance use disorder, with the goal of minimizing the negative effects of symptoms, emotional disturbances, or associated environmental stressors which interfere with the individual’s daily living, financial management, housing, academic and/or employment progress, personal recovery or resilience, family and/or interpersonal relationships, and community integration. Provide individual supportive counseling, solution-focused interventions, emotional and behavioral management support, and behavioral analysis with the individual, with the goal of assisting the individual with developing and implementing social, interpersonal, self-care, daily living, and independent living skills to restore stability, support functional gains, and adapt to community living. Facilitate participation in and utilization of strengths based planning and treatments which include assisting the individual and family members or other collaterals with identifying strengths and needs, resources, natural supports, and developing goals and objectives to utilize personal strengths, resources, and natural supports to address functional deficits associated with their mental illness and/or substance use disorder. Assist the individual with effectively responding to or avoiding identified precursors or triggers that would risk their remaining in a natural community location, including assisting the individual and family members or other collaterals with identifying a potential psychiatric or personal crisis, developing a crisis management plan, and/or seeking other supports to restore stability and functioning, as appropriate. CPST addresses specific individual needs with evidence-based and evidence-informed psychotherapeutic practices designed specifically to meet those needs. Examples include, but are not limited to: Cognitive Behavioral Therapy (CBT): CBT is an empirically-supported treatment that focuses on maladaptive patterns of thinking and the beliefs that underlie such thinking. This includes variations of CBT specific to the needs of an individual, such as Cognitive Processing Therapy. Dialectical Behavior Therapy (DBT): DBT is a form of CBT directed at individuals with borderline personality disorder or other disorders with chronic suicidal ideation and unstable relationships. It is a manual treatment program that provides support in managing chronic crisis and stress to keep individuals in outpatient treatment settings. It requires specialized training by the original developer or other entity approved by original developer (Marsha Linehan). The treatment program includes individual and group therapy sessions and requires homework by the individual. These therapies are provided by licensed therapists working under the direction of the HCBS provider agency.
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 35 §1915(i) State plan HCBS Approved: Supersedes:71 Additional needs-based criteria for receiving the service, if applicable (specify): Specify limits (if any) on the amount, duration, or scope of this service. Per 42 CFR Section 440.240, services available to any categorically needy recipient cannot be less in amount, duration and scope than those services available to a medically needy recipient, and services must be equal for any individual within a group. States must also separately address standard state plan service questions related to sufficiency of services. (Choose each that applies): 俶䢢 Categorically needy (specify limits): Community Psychiatric Support and Treatment (CPST) services are provided as part of a comprehensive specialized psychiatric program available to all Medicaid eligible adults with significant functional impairments meeting the need levels in the 1915(i). Medical necessity for these treatment services must be determined by a licensed behavioral health practitioner (LBHP) or physician who is acting within the scope of his/her professional license and applicable state law and furnished by or under the direction of a licensed practitioner to promote the maximum reduction of symptoms and/or restoration of an individual to his/her best age-appropriate functional level. The LBHP or physician may conduct an assessment consistent with state law, regulation, and policy. A unit of service is defined according to the HCPCS approved code set unless otherwise specified. If the determination of medical necessity for CPST requires additional assessment, this assessment may be conducted as part of the service up to one unit of the service. This service may not be provided on the same day and at the same time as services that contain elements integral to the delivery of this service. Medically needy (specify limits): N/A Provider Qualifications (For each type of provider. Copy rows as needed): Provider Type (Specify): License (Specify): Certification (Specify): Other Standard (Specify): HCBS Provider agency LPC, LMFT, LCSW, PhD psychologist, RN or MD (for individual therapists). Licensure candidates may provide services as part of a graduate education program under the direct supervision of an appropriately licensed professional. HCBS provider agency enrolled and contracted with HHSC to provide HCBS services, which employs or contracts with licensed practitioners with demonstrated competence in specialized mental health therapies. Direct-care therapists must be trained, credentialed, and demonstrate competence in the specialized psychotherapy practice used. Individual service providers must be determined to be a clinician under State regulations, meaning a person with a doctoral or master’s degree in psychology, counseling, social work, nursing, rehabilitation, or related field from an accredited college or university (or a registered nurse with a certificate in mental health nursing from the American Nurses Association). Verification of Provider Qualifications (For each provider type listed above. Copy rows as needed): Provider Type (Specify): Entity Responsible for Verification (Specify): Frequency of Verification (Specify): HCBS Provider agency that meets HHSC Annual
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 36 §1915(i) State plan HCBS Approved: Supersedes:71 the minimum eligibility and standards for HCBS- AMH provider enrollment. Service Delivery Method. (Check each that applies): Participant-directed 俶䢢Provider managed Service Specifications (Specify a service title for the HCBS listed in Attachment 4.19-B that the state plans to cover): Service Title: Peer Support Service Definition (Scope): Peer support services are provided by self-identified consumers who are in recovery from mental illness and/or substance use disorders. Peer support specialists use their own experiences with mental illness, substance use disorder (SUD), and/or another co-occurring disorders (such as a chronic health condition), to help individuals reach their recovery goals. Peer support providers are supervised by mental health professionals or licensed SUD treatment providers, working under the direction of the HCBS provider agency, and are trained to deliver peer services. The services are coordinated within the context of a comprehensive, individual recovery plan that includes specific individualized goals and delineates activities intended to achieve the identified goals. Peer Support services promote coping skills, facilitate use of natural resources/supports, and enhance recovery- oriented attributes such as hope and self-efficacy. The activities provided by this service emphasize the opportunity for consumers to support each other in the restoration and expansion of the skills and strategies necessary to move forward in recovery. Additional needs-based criteria for receiving the service, if applicable (specify): Specify limits (if any) on the amount, duration, or scope of this service. Per 42 CFR Section 440.240, services available to any categorically needy recipient cannot be less in amount, duration and scope than those services available to a medically needy recipient, and services must be equal for any individual within a group. States must also separately address standard state plan service questions related to sufficiency of services. (Choose each that applies): 俶䢢 Categorically needy (specify limits): Peer Support is available daily, limited to no more than four hours per day for an individual client. Progress notes document the individual’s progress relative to goals identified in the IRP. Peer services are not a substitute for or adjunct to other HCBS services such as HCBS Psychosocial Rehabilitation or Community Psychiatric Supports and Treatment. Medically needy (specify limits): N/A Provider Qualifications (For each type of provider. Copy rows as needed): Provider Type (Specify): License (Specify): Certification (Specify): Other Standard (Specify): HCBS Provider Agency that meets the minimum eligibility and standards for HCBS- AMH provider enrollment. Peer Specialists must be recognized under a HHSC- approved process for MH or SUD peers. HCBS provider agency enrolled and contracted with HHSC to provide HCBS services, which employs or has agreements with recognized Peer Specialists. Individual providers must maintain a HHSC- approved certification to be mental health or substance use disorder peer specialists. At
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 37 §1915(i) State plan HCBS Approved: Supersedes:71S minimum, individuals must also be 18 years of age or older and have common life experiences with the individual, such as having a mental health or substance use condition, using services or supports for mental health and substance use conditions, and being in a recovery process. Verification of Provider Qualifications (For each provider type listed above. Copy rows as needed): Provider Type (Specify): Entity Responsible for Verification (Specify): Frequency of Verification (Specify): HCBS Provider Agency that meets the minimum eligibility and standards for HCBS- AMH provider enrollment. HHSC Annual Service Delivery Method. (Check each that applies): Participant-directed 俶䢢Provider managed Service Specifications (Specify a service title for the HCBS listed in Attachment 4.19-B that the state plans to cover): Service Title: Host Home/Companion Care Service Definition (Scope): Host Home/Companion Care services are supportive and health-related residential services provided to individuals in the individual’s own home or in settings licensed or approved by the State of Texas. Host Home/Companion Care services are necessary, as specified in the individuals person-directed IRP, to enable the individual to remain integrated in the community and ensure the health, welfare, and safety of the individual in accordance with 42 C.F.R. § 441.710. (Refer to Section 9 “Home and Community-Based Settings” for HCBS- AMH settings requirements.) Community-based residential services include personal care and supportive services (homemaker, chores, attendant services, and meal preparation) that are furnished to individuals who reside in homelike, non-institutional, integrated settings. In addition, they include 24-hour onsite response capability to meet scheduled and unscheduled or unpredictable resident needs and to provide supervision and safety. Services also include social and recreational programming and medication assistance (to the extent permitted under state law). Home and Community-Based Settings must: Be integrated in and support full access to the greater community, including opportunities to seek employment and work in competitive integrated settings, engage in community life, control personal resources, and receive services in the community, to the same degree of access as individuals not receiving Medicaid HCBS. Be selected by the individual from among setting options including non-disability specific settings and an option for a private unit in a residential setting. Ensure rights of privacy, dignity and respect, and freedom from coercion and restraint. Optimize, but not regiment, individual initiative, autonomy, and independence in making life choices, daily activities, physical environment, and with whom to interact. Facilitate individual choice regarding services and supports, and who provides them Host home/companion care services promote recovery by supporting individual recovery goals, using natural supports and typical community services available to all people, enabling social interaction and participation in leisure activities, and helping the individual develop daily living and functional living skills. This service also fosters the individual’s recovery and independence by providing personal assistance with activities of daily living (grooming, eating, bathing, dressing, and personal hygiene) and functional living tasks; assistance with planning and preparing meals; transportation or assistance in securing transportation; assistance with ambulation and mobility; reinforcement of specialized rehabilitative, habilitative, or psychosocial therapies/activities; assistance with medications based upon the results of an RN assessment and the performance of tasks delegated by a RN in
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 38 §1915(i) State plan HCBS Approved: Supersedes:71 accordance with the Texas Board of Nursing rules as defined by Title 22 of the Texas Administrative Code, Part 11, Chapter 225; and supervision of the individual’s safety and security. Host home/companion care is provided in a private residence meeting HCBS requirements by a host home or companion care provider who lives in the residence. In a host home arrangement, the host home provider owns or leases the residence. In a companion care arrangement, the residence may be owned or leased by the companion care provider or may be owned or leased by the individual. Transportation costs are included in the rate. Type and frequency of supervision is determined on an individual basis based on the level of need for each individual. The HCBS-AMH provider agency will be encouraged to hire providers to deliver personal care services separate from those who provide rehabilitation services, if there is more than one provider on-site at the residence during normal hours who can provide personal care services. This will ensure that the clinical boundary issues that would otherwise complicate rehabilitation services (if the same staff were also delivering personal care services) will be mitigated. The individual receiving Host Home/Companion Care services has a right to privacy. Sleeping and individual living units may be locked at the discretion of the individual, with keys available only to appropriate providers or landlords. Provider access to living units will be documented in the IRP. The IRP will identify when persons other than the individual have access, what types of persons have access, and under what circumstances staff will be allowed to access an individual’s unit. In order to justify a modification of person-centered residence requirements, the IRP must document: a specific and individualized assessed need; the positive interventions and supports used prior to any modifications; less intrusive methods of meeting the need that have been tried but did not work; a clear description of the condition that is directly proportionate to the specific assessed need; regular collection and review of data to measure the ongoing effectiveness of the modification; established time limits for periodic reviews to determine if the modification is still necessary or can be terminated; informed consent of the individual; and assurance that interventions and supports will cause no harm to the individual. Individuals have the freedom and support to control their own schedules and activities, and have access to food and visitors of their choosing at any time, and have the freedom to furnish and decorate units. Settings facilitate individual choice regarding services and supports and who provide them. Each living unit is separate and distinct from each other. The individual retains the right to assume risk, tempered only by the individual’s ability to assume responsibility for that risk. Services must be furnished in a way that fosters the independence of each individual to facilitate recovery. Routines of service delivery must be individual- driven to the maximum extent possible and each individual must be treated with dignity and respect. The IRP will document any planned intervention which could potentially impinge on individual autonomy. Documentation will include informed consent of the individual to the intervention; the specific need for the intervention in supporting the individual to achieve his/her goals; assurance that the intervention is the most inclusive and person-centered option; time limits for the intervention, periodic reviews of the intervention to determine if it is still needed, and assurance that the intervention will cause no harm to the individual. This service will be provided to meet the individual’s needs as determined by an individualized assessment performed in accordance HHSC requirements and as outlined in the individual’s IRP. Host Home/Companion Care services are available to individuals as they are determined necessary, based upon a quarterly assessment documented in the IRP and approved by HHSC. HHSC will review the authorized residential service on an ongoing basis to ensure that it is community-based, inclusive, and meets federal and state HCBS setting requirements. HHSC staff will conduct biennial reviews of residential services in all settings, and will conduct unannounced site visits to provider owned or operated settings. If the monitoring suggests that a change in service is needed, an independent re-assessment will be conducted by HHSC or its designee to re-evaluate the participant to determine the appropriateness of the service in accordance with HHSC requirements. The HCBS-AMH provider agency must implement and maintain a plan for initial and periodic training of staff members and service providers that ensures staff members and service providers are qualified to deliver services as required by the current needs and characteristics of the individuals to whom they deliver services and are knowledgeable of acts that constitute abuse, neglect, or exploitation of an individual and methods to prevent the occurrence of abuse, neglect, and exploitation. Periodic training is delivered by the HCBS-AMH provider agency, as needed, to ensure service providers are
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 39 §1915(i) State plan HCBS Approved: Supersedes:71 qualified to provide HCBS-AMH services in accordance with state and federal laws and regulations); and to ensure the individual’s safety and security. Periodic training is delivered by the HCBS-AMH provider agency, as needed, to ensure service providers are qualified to provide HCBS-AMH services in accordance with state and federal laws and regulations); and to ensure the individual’s safety and security. Additional needs-based criteria for receiving the service, if applicable (specify): Specify limits (if any) on the amount, duration, or scope of this service. Per 42 CFR Section 440.240, services available to any categorically needy recipient cannot be less in amount, duration and scope than those services available to a medically needy recipient, and services must be equal for any individual within a group. States must also separately address standard state plan service questions related to sufficiency of services. (Choose each that applies): 俶䢢 Categorically needy (specify limits): Payments for Host-home/Companion Care are not made for room and board, items of comfort or convenience, or the costs of facility maintenance, upkeep, and improvement. An individual may receive only one type of residential assistance (Host-home/Companion Care, Assisted Living, Supervised Living, or Supported Home Living) at a time. Separate payments will not be made for respite, personal assistance, home-delivered meals, minor home modifications, non-medical transportation, or transition assistance services for individuals who receive Host-Home/Companion Care in provider owned or operated settings. Individuals receiving adult foster care or Department of Family and Protective Services foster care services may not also receive Host Home/Companion Care services. Texas ensures duplication of services does not occur by prohibiting payment for services without authorization. Two entities may not be paid for providing the same service to the same individual during the same time period. Individuals are responsible for their room and board costs. This service may not be provided on the same day and at the same time as services that contain elements integral to the delivery of this service. Services that are provided by third parties must be coordinated with the Host Home/Companion Care provider and through the recovery manager, including community-based rehabilitative services provided outside of the residence. Host Home/Companion Care services should be provided only in settings within Texas, which meet home and community-based characteristic requirements for the type of residential support provided. Residential services cannot be provided in or on the grounds of the following settings: • Nursing facilities; • Institutions for mental disease; • Intermediate care facilities for individuals with Intellectual or Developmental Disabilities; • Inpatient hospitals; or • Any other location that has qualities of an institutional setting. Medically needy (specify limits): N/A Provider Qualifications (For each type of provider. Copy rows as needed): Provider Type (Specify): License (Specify): Certification (Specify): Other Standard (Specify): HCBS Provider agency that meets HCBS provider agency enrolled and contracted with HHSC to provide HCBS
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 40 §1915(i) State plan HCBS Approved: Supersedes:71 the minimum eligibility and standards for HCBS- AMH provider enrollment. services, which employs or has agreements with Host Home/Companion Care Providers. Residential settings must meet relevant state and local requirements. Individual direct service providers must be at least 18 years of age. The employee provider must have a high school diploma or Certificate of High School Equivalency (GED credentials) or documentation of a proficiency evaluation of experience and competence to perform job tasks including ability to provide the required services as needed by the individual to be served as demonstrated through a written competency-based assessment. The individual provider must pass a criminal background check and also have at least three personal references from persons not related within three degrees of consanguinity that evidence the ability to provide a safe and healthy environment for the individual(s) to be served. Transportation of individuals must be provided in accordance with applicable state laws. Individuals transporting individuals must be 18 years of age or older; pass a criminal background check; and must have a valid driver's license and proof of insurance. Assisting with tasks delegated by an RN must be in accordance with state law. Individual providers of Host Home/Companion Care must complete initial and periodic training provided by HCBS provider agency which includes HHSC- required training in the HCBS-AMH program. Before entering into a provider agreement with the provider agency, HHSC verifies the providers’ compliance with these qualifications through a credentialing process. Contracted providers are obligated to verify on an ongoing basis that these qualifications are achieved, maintained, and documented in personnel files. HHSC will conduct annual review to verify these requirements continue to be met after the provider and HHSC enter into an agreement. Verification of Provider Qualifications (For each provider type listed above. Copy rows as needed): Provider Type (Specify): Entity Responsible for Verification (Specify): Frequency of Verification (Specify): HCBS Provider Agency that meets HHSC Annual
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 41 §1915(i) State plan HCBS Approved: Supersedes:71 the minimum eligibility and standards for HCBS- AMH provider enrollment. Service Delivery Method. (Check each that applies): Participant-directed 俶䢢Provider managed Service Specifications (Specify a service title for the HCBS listed in Attachment 4.19-B that the state plans to cover): Service Title: Supervised Living Services Service Definition (Scope): Supervised Living Services are supportive and health-related residential services provided to individuals in settings licensed or approved by the State of Texas. Residential services are necessary, as specified in the individuals person-directed IRP, to enable the individual to remain integrated in the community and ensure the health, welfare, and safety of the individual in accordance with 42 C.F.R. § 441.710. (Refer to Section 9 “Home and Community-Based Settings” for HCBS-AMH settings requirements.) Supervised Living Services include personal care and supportive services (homemaker, chores, attendant services, and meal preparation) that are furnished to individuals who reside in homelike, non-institutional, integrated settings. In addition, they include 24-hour onsite response capability to meet scheduled and unscheduled or unpredictable resident needs and to provide supervision and safety. Services also include social and recreational programming and medication assistance (to the extent permitted under state law). Home and Community-Based Settings must: Be integrated in and support full access to the greater community, including opportunities to seek employment and work in competitive integrated settings, engage in community life, control personal resources, and receive services in the community, to the same degree of access as individuals not receiving Medicaid HCBS. Be selected by the individual from among setting options including non-disability specific settings and an option for a private unit in a residential setting. Ensure rights of privacy, dignity and respect, and freedom from coercion and restraint. Optimize, but not regiment, individual initiative, autonomy, and independence in making life choices, daily activities, physical environment, and with whom to interact. Facilitate individual choice regarding services and supports, and who provides them Supervised Living Services promote recovery by supporting individual recovery goals, using natural supports and typical community services available to all people, enabling social interaction and participation in leisure activities, and helping the individual develop daily living and functional living skills. Supervised living also fosters recovery and independence by providing individuals with personal assistance with activities of daily living (grooming, eating, bathing, dressing, and personal hygiene) and functional living tasks; assistance with planning and preparing meals; transportation or assistance in securing transportation; assistance with ambulation and mobility; reinforcement of specialized rehabilitative, habilitative or psychosocial therapies; assistance with medications based upon the results of an RN assessment; the performance of tasks delegated by a RN in accordance with the Texas Board of Nursing rules as defined by Title 22 of the Texas Administrative Code, Part 11, Chapter 225; and supervision of the individual’s safety and security. Transportation costs included in the rate for the supervised living service are for providing transportation to the participant and not provider staff. Supervised living provides residential assistance as needed by individuals who live in residences in which the HCBS provider holds a property interest and that meet program certification standards. This service may be provided to individuals in one of two modalities: By providers who are not awake during normal sleep hours but are present in the residence and able to respond to the needs of individuals during normal sleeping hours; or By providers assigned on a shift schedule that includes at least one complete change of staff each day. Transportation costs are included in the rate. Type and frequency of supervision is determined on an individual basis based on the level of need for each individual. The individual receiving supervised living services has a right to privacy. Sleeping and individual living units may be locked at the discretion of the individual, with keys available only to appropriate staff or landlords. Staff
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 42 §1915(i) State plan HCBS Approved: Supersedes:71 access to living units will be documented in the IRP. The IRP will identify when staff members have access, what types of staff have access, and under what circumstances staff will be allowed to access an individual’s unit. In order to justify a modification of person-centered residence requirements, the IRP must document: a specific and individualized assessed need; the positive interventions and supports used prior to any modifications; less intrusive methods of meeting the need that have been tried but did not work; a clear description of the condition that is directly proportionate to the specific assessed need; regular collection and review of data to measure the ongoing effectiveness of the modification; established time limits for periodic reviews to determine if the modification is still necessary or can be terminated; informed consent of the individual; and assurance that interventions and supports will cause no harm to the individual. Individuals have the freedom and support to control their own schedules and activities, and have access to food and visitors of their choosing at any time, and have the freedom to furnish and decorate units. Settings facilitate individual choice regarding services and supports and who provide them. Each living unit is separate and distinct from each other. The individual retains the right to assume risk, tempered only by the individual’s ability to assume responsibility for that risk. Services must be furnished in a way that fosters the independence of each individual to facilitate recovery. Routines of service delivery must be individual- driven to the maximum extent possible and each individual must be treated with dignity and respect. The IRP will document any planned intervention which could potentially impinge on individual autonomy. Documentation will include informed consent of the individual to the intervention; the specific need for the intervention in supporting the individual to achieve his/her goals; assurance that the intervention is the most inclusive and person-centered option; time limits for the intervention, periodic reviews of the intervention to determine if it is still needed, and assurance that the intervention will cause no harm to the individual. The HCBS AMH provider agency will be encouraged to hire providers to deliver personal care services separate from those who provide rehabilitation services, if there is more than one provider on-site at the residence during normal hours who can provide personal care services. This will ensure that the clinical boundary issues that would otherwise complicate rehabilitation services (if the same staff were also delivering personal care services) will be mitigated. This service will be provided to meet the individual’s needs as determined by an individualized assessment performed in accordance HHSC requirements and as outlined in the individual’s IRP. Supervised Living Services are available to individuals as they are determined necessary, based upon a quarterly assessment documented in the IRP and approved by HHSC. HHSC will review the authorized residential service on an ongoing basis to ensure that it is community- based, inclusive, and meets federal and state HCBS setting requirements. HHSC staff will conduct biennial reviews of residential services in all settings, and will conduct unannounced site visits to provider owned or operated settings. HHSC conducts biennial on-site reviews of community-based settings to ensure that settings do not have the qualities of an institutional setting, meet HCB setting requirements, and promote choice and community inclusion. If the monitoring suggests that a change in service is needed, an independent re-assessment will be conducted by HHSC or its designee to re-evaluate the participant to determine the appropriateness of the service in accordance with HHSC requirements. The HCBS-AMH provider agency must implement and maintain a plan for initial and periodic training of staff members and service providers that ensures staff members and service providers are qualified to deliver services as required by the current needs and characteristics of the individuals to whom they deliver services and are knowledgeable of acts that constitute abuse, neglect, or exploitation of an individual and methods to prevent the occurrence of abuse, neglect, and exploitation. Periodic training is delivered by the HCBS-AMH provider agency, as needed, to ensure service providers are qualified to provide HCBS-AMH services in accordance with state and federal laws and regulations); and to ensure the individual’s safety and security. Additional needs-based criteria for receiving the service, if applicable (specify):
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 43 §1915(i) State plan HCBS Approved: Supersedes:71 Specify limits (if any) on the amount, duration, or scope of this service. Per 42 CFR Section 440.240, services available to any categorically needy recipient cannot be less in amount, duration and scope than those services available to a medically needy recipient, and services must be equal for any individual within a group. States must also separately address standard state plan service questions related to sufficiency of services. (Choose each that applies): 俶䢢 Categorically needy (specify limits): Supervised living services can only be provided in settings approved by HHSC or in licensed assisted living facilities with no more than 4 beds. HHSC approved settings with more than four beds must maintain a staffing ratio of 4:1. Payments for Supervised Living are not made for room and board, items of comfort or convenience, or the costs of facility maintenance, upkeep, and improvement. An individual may receive only one type of residential assistance (Host-home/Companion Care, Assisted Living, Supervised Living, or Supported Home Living) at a time. Separate payments will not be made for respite, personal assistance, home-delivered meals, minor home modifications, non-medical transportation, or transition assistance services for individuals who receive Supervised Living in provider owned or operated settings. Individuals receiving adult foster care or Department of Family and Protective Services foster care services may not also receive Supervised Living Services. Texas ensures duplication of services does not occur by prohibiting payment for services without authorization. Two entities may not be paid for providing the same service to the same individual during the same time period. Individuals are responsible for their room and board costs. This service may not be provided on the same day and at the same time as services that contain elements integral to the delivery of this service. Services that are provided by third parties must be coordinated with the Supervised Living Services provider and through the recovery manager, including community-based rehabilitative services provided outside of the residence. Supervised Living Services should be provided only in settings within Texas, which meet home and community-based characteristic requirements for the type of residential support provided. Supervised Living Services cannot be provided in or on the grounds of the following settings: • Nursing facilities; • Institutions for mental disease; • Intermediate care facilities for individuals with Intellectual or Developmental Disabilities; • Inpatient hospitals; or • Any other location that has qualities of an institutional setting. Medically needy (specify limits): N/A Provider Qualifications (For each type of provider. Copy rows as needed): Provider Type (Specify): License (Specify): Certification (Specify): Other Standard (Specify): HCBS Provider agency that meets the minimum eligibility and standards for HCBS- AMH provider enrollment. HCBS provider agency enrolled and contracted with HHSC to provide HCBS services, which employs or has agreements with Supervised Living Services Providers. Residential settings must meet relevant state and local requirements.
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 44 §1915(i) State plan HCBS Approved: Supersedes:71 Individual direct service providers must be at least 18 years of age. The employee provider must have a high school diploma or Certificate of High School Equivalency (GED credentials) or documentation of a proficiency evaluation of experience and competence to perform job tasks including ability to provide the required services as needed by the individual to be served as demonstrated through a written competency-based assessment. The individual provider must pass a criminal background check and also have at least three personal references from persons not related within three degrees of consanguinity that evidence the ability to provide a safe and healthy environment for the individual(s) to be served. Transportation of individuals must be provided in accordance with applicable state laws. Individuals transporting individuals must be 18 years of age or older; pass a criminal background check; and must have a valid driver's license and proof of insurance. Assisting with tasks delegated by an RN must be in accordance with state law. Individual providers of Supervised Living Services must complete initial and periodic training provided by HCBS provider agency which includes HHSC-required training in the HCBS-AMH program. Before entering into a provider agreement with the provider agency, HHSC verifies the providers’ compliance with these qualifications through a credentialing process. Contracted providers are obligated to verify on an ongoing basis that these qualifications are achieved, maintained, and documented in personnel files. HHSC will conduct annual review to verify these requirements continue to be met after the provider and HHSC enter into an agreement. Verification of Provider Qualifications (For each provider type listed above. Copy rows as needed): Provider Type (Specify): Entity Responsible for Verification (Specify): Frequency of Verification (Specify): HCBS Provider Agency that meets the minimum eligibility and standards for HCBS- AMH provider enrollment. HHSC Annual Service Delivery Method. (Check each that applies):
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 45 §1915(i) State plan HCBS Approved: Supersedes:71 Participant-directed 俶䢢Provider managed Service Specifications (Specify a service title for the HCBS listed in Attachment 4.19-B that the state plans to cover): Service Title: Assisted Living Services Service Definition (Scope): Assisted Living Services are supportive and health-related residential services provided to individuals in settings licensed or approved by the State of Texas. Residential services are necessary, as specified in the individuals person-directed IRP, to enable the individual to remain integrated in the community and ensure the health, welfare, and safety of the individual in accordance with 42 C.F.R. § 441.710. (Refer to Section 9 “Home and Community-Based Settings” for HCBS-AMH settings requirements.) Assisted Living Services include personal care and supportive services (homemaker, chores, attendant services, and meal preparation) that are furnished to individuals who reside in homelike, non-institutional, integrated settings. In addition, they include 24-hour onsite response capability to meet scheduled and unscheduled or unpredictable resident needs and to provide supervision and safety. Services also include social and recreational programming and medication assistance (to the extent permitted under state law). Home and Community-Based Settings must: Be integrated in and support full access to the greater community, including opportunities to seek employment and work in competitive integrated settings, engage in community life, control personal resources, and receive services in the community, to the same degree of access as individuals not receiving Medicaid HCBS. Be selected by the individual from among setting options including non-disability specific settings and an option for a private unit in a residential setting. Ensure rights of privacy, dignity and respect, and freedom from coercion and restraint. Optimize, but not regiment, individual initiative, autonomy, and independence in making life choices, daily activities, physical environment, and with whom to interact. Facilitate individual choice regarding services and supports, and who provides them Assisted Living Services are personal care, homemaker, and chore services; medication oversight; and therapeutic, social, and recreational programming provided in a home-like environment in a licensed community setting in conjunction with residing in the assisted living setting. This service includes 24-hour on- site response staff to meet scheduled or unpredictable needs in a way that promotes maximum dignity and independence, and to provide supervision, safety, and security. Other individuals or agencies may also furnish care directly or under arrangement with the community setting, but the services provided by these other entities supplement that provided by the community setting and do not supplant it. Assisted living is furnished to individuals who reside in their own living units/ bedrooms, which may include dually-occupied units when both occupants consent to the arrangement, that contain toilet facilities, and may or may not include kitchenette and/or living rooms. The assisted living setting must have a central dining room; living room or parlor; and/or common activity center(s) (which may also serve as living rooms or dining rooms). Individuals have the freedom and support to control their own schedules and activities, have access to food and visitors of their choosing at any time, have access at any time to the common/shared areas (including kitchens, living rooms, and activity centers), and have the freedom to furnish and decorate units. Individuals in assisted living settings, where units do not have a private kitchen/kitchenette and/or living room or parlor, have full access to a shared kitchen with cooking facilities and comfortable seating in the shared areas for private visits with family and friends. The HCBS AMH provider agency will be encouraged to hire providers to deliver personal care services separate from those who provide rehabilitation services, if there is more than one provider on-site at the residence during normal hours who can provide personal care services. This will ensure that the clinical boundary issues that would otherwise complicate rehabilitation services (if the same staff were also delivering personal care services) will be mitigated. This service will be provided to meet the individual’s needs as determined by an individualized assessment performed in accordance HHSC requirements and as outlined in the individual ’s IRP. Assisted Living Services are available to individuals as they are determined necessary, based upon a quarterly assessment documented in the IRP and approved by HHSC.
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 46 §1915(i) State plan HCBS Approved: Supersedes:71 The individual receiving Assisted Living Services has a right to privacy. Sleeping and individual living units may be locked at the discretion of the individual, with keys available only to appropriate staff or landlords. Staff access to living units will be documented in the IRP. The IRP will identify when staff members have access, what types of staff have access, and under what circumstances staff will be allowed to access an individual’s unit. In order to justify a modification of person-centered residence requirements the IRP must document: a specific and individualized assessed need; the positive interventions and supports used prior to any modifications; less intrusive methods of meeting the need that have been tried but did not work; a clear description of the condition that is directly proportionate to the specific assessed need; regular collection and review of data to measure the ongoing effectiveness of the modification; established time limits for periodic reviews to determine if the modification is still necessary or can be terminated; informed consent of the individual; and assurance that interventions and supports will cause no harm to the individual. Settings facilitate individual choice regarding services and supports and who provides them. Each living unit is separate and distinct from each other. The individual retains the right to assume risk, tempered only by the individual’s ability to assume responsibility for that risk. Services must be furnished in a way that fosters the independence of each individual to facilitate recovery. Routines of service delivery must be individual- driven to the maximum extent possible and each individual must be treated with dignity and respect. The IRP will document any planned intervention which could potentially impinge on individual autonomy. Documentation will include informed consent of the individual to the intervention; the specific need for the intervention in supporting the individual to achieve his/her goals; assurance that the intervention is the most inclusive and person-centered option; time limits for the intervention, periodic reviews of the intervention to determine if it is still needed, and assurance that the intervention will cause no harm to the individual. HHSC will review the authorized residential service on an ongoing basis to ensure that it is community-based, inclusive, and meets federal and state HCBS setting requirements. HHSC staff will conduct biennial reviews of residential services in all settings, and will conduct unannounced site visits to provider owned or operated settings. HHSC conducts biennial on-site reviews of community-based settings to ensure that settings do not have the qualities of an institutional setting, meet HCB setting requirements, and promote choice and community inclusion. If the monitoring suggests that a change in service is needed, an independent re-assessment will be conducted by HHSC or its designee to re-evaluate the participant to determine the appropriateness of the service in accordance with HHSC requirements. The HCBS-AMH provider agency must implement and maintain a plan for initial and periodic training of staff members and service providers that ensures staff members and service providers are qualified to deliver services as required by the current needs and characteristics of the individuals to whom they deliver services and are knowledgeable of acts that constitute abuse, neglect, or exploitation of an individual and methods to prevent the occurrence of abuse, neglect, and exploitation. Periodic training is delivered by the HCBS-AMH provider agency, as needed, to ensure service providers are qualified to provide HCBS-AMH services in accordance with state and federal laws and regulations); and to ensure the individual’s safety and security. Additional needs-based criteria for receiving the service, if applicable (specify): Specify limits (if any) on the amount, duration, or scope of this service. Per 42 CFR Section 440.240, services available to any categorically needy recipient cannot be less in amount, duration and scope than those services available to a medically needy recipient, and services must be equal for any individual within a group. States must also separately address standard state plan service questions related to sufficiency of services. (Choose each that applies): 俶䢢 Categorically needy (specify limits): Payments for Assisted Living are not made for room and board, items of comfort or convenience, or the costs of facility maintenance, upkeep, and improvement. An individual may receive only one type of residential assistance (Host-home/Companion Care, Assisted Living, Supervised Living, or Supported Home Living) at a time. Separate payments will not be made for respite, personal assistance, home-delivered meals, minor home modifications, non-medical transportation, or transition assistance services for individuals who receive
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 47 §1915(i) State plan HCBS Approved: Supersedes:71 Assisted Living. Individuals receiving adult foster care or Department of Family and Protective Services foster care services may not also receive Assisted Living Services. Nursing and skilled therapy services (except periodic nursing evaluations) are incidental, rather than integral to providing assisted living services. Payment will not be made for 24-hour skilled care. Texas ensures duplication of services does not occur by prohibiting payment for services without authorization. Two entities may not be paid for providing the same service to the same individual during the same time period. Individuals are responsible for their room and board costs. This service may not be provided on the same day and at the same time as services that contain elements integral to the delivery of this service. Services that are provided by third parties must be coordinated with the Assisted Living Services provider and through the recovery manager, including community-based rehabilitative services provided outside of the residence. Assisted Living Services should be provided only in settings within Texas, which meet home and community-based characteristic requirements for the type of residential support provided. Assisted Living Services cannot be provided in or on the grounds of the following settings: • Nursing facilities; • Institutions for mental disease; • Intermediate care facilities for individuals with Intellectual or Developmental Disabilities; • Inpatient hospitals; or • Any other location that has qualities of an institutional setting. Medically needy (specify limits): Provider Qualifications (For each type of provider. Copy rows as needed): Provider Type (Specify): License (Specify): Certification (Specify): Other Standard (Specify): HCBS Provider agency that meets the minimum eligibility and standards for HCBS- AMH provider enrollment. HCBS provider agency enrolled and contracted with HHSC to provide HCBS services, which employs or has agreements with Assisted Living Services Providers. Residential settings must meet relevant state and local requirements. Individual direct service providers must be at least 18 years of age. The provider must have a high school diploma or Certificate of High School Equivalency (GED credentials) or documentation of a proficiency evaluation of experience and competence to perform job tasks including ability to provide the required services as needed by the individual to be served as demonstrated through a written competency-based assessment. The individual provider must pass a criminal background check and also have at least three personal references from persons not related within three degrees of consanguinity that evidence the ability to provide a safe and healthy
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 48 §1915(i) State plan HCBS Approved: Supersedes:71 environment for the individual(s) to be served. Transportation of individuals must be provided in accordance with applicable state laws. Individuals transporting individuals must be 18 years of age or older; pass a criminal background check; and must have a valid driver's license and proof of insurance. Assisting with tasks delegated by an RN must be in accordance with state law. Individual providers of Assisted Living Services must complete initial and periodic training provided by HCBS provider agency which includes HHSC-required training in the HCBS-AMH program. Before entering into a provider agreement with the provider agency, HHSC verifies the providers’ compliance with these qualifications through a credentialing process. Contracted providers are obligated to verify on an ongoing basis that these qualifications are achieved, maintained, and documented in personnel files. HHSC will conduct annual review to verify these requirements continue to be met after the provider and HHSC enter into an agreement. Verification of Provider Qualifications (For each provider type listed above. Copy rows as needed): Provider Type (Specify): Entity Responsible for Verification (Specify): Frequency of Verification (Specify): HCBS Provider Agency that meets the minimum eligibility and standards for HCBS- AMH provider enrollment. HHSC Annual Service Delivery Method. (Check each that applies): Participant-directed 俶䢢Provider managed Service Specifications (Specify a service title for the HCBS listed in Attachment 4.19-B that the state plans to cover): Service Title: Supported Home Living Service Definition (Scope): Supported Home Living services are supportive and health-related residential services provided to individuals in their own home or family home or in a setting licensed or approved by the State of Texas. Residential services are necessary, as specified in the individuals person-directed IRP, to enable the individual to remain integrated in the community and ensure the health, welfare, and safety of the individual in accordance with 42 CFR § 441.710. (Refer to Section 9 “Home and Community-Based Settings” for HCBS-AMH settings requirements.) Supported Home Living services include personal care and supportive services (homemaker, chores, attendant services, and meal preparation) that are
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 49 §1915(i) State plan HCBS Approved: Supersedes:71 furnished to individuals who reside in homelike, non- institutional, integrated settings. Services also include social and recreational programming and medication assistance (to the extent permitted under state law). Home and Community-Based Settings must: Be integrated in and support full access to the greater community, including opportunities to seek employment and work in competitive integrated settings, engage in community life, control personal resources, and receive services in the community, to the same degree of access as individuals not receiving Medicaid HCBS. Be selected by the individual from among setting options including non-disability specific settings and an option for a private unit in a residential setting. Ensure rights of privacy, dignity and respect, and freedom from coercion and restraint. Optimize, but not regiment, individual initiative, autonomy, and independence in making life choices, daily activities, physical environment, and with whom to interact. Facilitate individual choice regarding services and supports, and who provides them Supported Home Living services assist individuals living in community-based residences. Supported home living promotes individual recovery and community inclusion by providing individuals with direct personal assistance with activities of daily living (grooming, eating, bathing, dressing, and personal hygiene) and functional living tasks; assistance with planning and preparing meals; transportation or assistance in securing transportation; assistance with ambulation and mobility; reinforcement specialized rehabilitative, habilitative, or psychosocial mental health therapies/activities; assistance with medications and the performance of tasks delegated by a registered nurse in accordance with the Texas Board of Nursing rules as defined by Title 22 of the Texas Administrative Code, Part 11, Chapter 225; and supervision as needed to ensure the individual’s health and safety; and supervision of the individual’s safety and security. This service includes activities that facilitate the individual’s inclusion in community activities, use of natural supports and typical community services available to all people, social interaction, and participation in leisure activities, and development of socially valued behaviors and daily living and functional living skills. Services must be furnished in a way that fosters the independence of each individual to facilitate recovery. Routines of service delivery must be individual-driven to the maximum extent possible and each individual must be treated with dignity and respect. The IRP will document any planned intervention which could potentially impinge on individual autonomy. Documentation will include informed consent of the individual to the intervention; the specific need for the intervention in supporting the individual to achieve his/her goals; assurance that the intervention is the most inclusive and person-centered option; time limits for the intervention, periodic reviews of the intervention to determine if it is still needed, and assurance that the intervention will cause no harm to the individual. The individual receiving supported home living has a right to privacy. Sleeping and individual living units may be locked at the discretion of the individual, with keys available only to landlords or appropriate service providers. Service providers with access to living units will be documented in the IRP. The IRP will identify when service providers have access, what types of service providers have access, and under what circumstances service providers will be allowed to access an individual’s unit. In order to justify a modification of person- centered residence requirements, the IRP must document: a specific and individualized assessed need; the positive interventions and supports used prior to any modifications; less intrusive methods of meeting the need that have been tried but did not work; a clear description of the condition that is directly proportionate to the specific assessed need; regular collection and review of data to measure the ongoing effectiveness of the modification; established time limits for periodic reviews to determine if the modification is still necessary or can be terminated; informed consent of the individual; and assurance that interventions and supports will cause no harm to the individual. Supported Home Living services can be provided to individuals residing in their own or family
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 50 §1915(i) State plan HCBS Approved: Supersedes:71 residence. When supported home living, is provided to individuals residing with their family members, it is designed to support rather than supplant the family and natural supports. Individuals residing in their own homes receive supported home living as necessary, based on the individual's IRP, to support them in their independent residence. Transportation provided to individuals in accordance with HHSC guidelines is a billable supported home living service. Transportation costs which are not billable, but which are incurred to provide the supported home living service, are included in the indirect portion of the rate. This service will be provided to meet the individual’s needs as determined by an individualized assessment performed in accordance HHSC requirements and as outlined in the individual’s IRP. Supported home living services are available to individuals as they are determined necessary, based upon a quarterly assessment documented in the IRP and approved by HHSC. HHSC will review the authorized residential service on an ongoing basis to ensure that it is community-based, inclusive, and meets federal and state HCBS setting requirements. HHSC staff will conduct biennial reviews of residential services in all settings, and will conduct unannounced site visits to provider owned or operated settings. HHSC conducts biennial on-site reviews of community-based settings to ensure that settings do not have the qualities of an institutional setting, meet HCB setting requirements, and promote choice and community inclusion. If the monitoring suggests that a change in service is needed, an independent re-assessment will be conducted by HHSC or its designee to re-evaluate the participant to determine the appropriateness of the service in accordance with HHSC requirements. The HCBS-AMH provider agency must implement and maintain a plan for initial and periodic training of staff members and service providers that ensures staff members and service providers are qualified to deliver services as required by the current needs and characteristics of the individuals to whom they deliver services and are knowledgeable of acts that constitute abuse, neglect, or exploitation of an individual and methods to prevent the occurrence of abuse, neglect, and exploitation. Periodic training is delivered by the HCBS-AMH provider agency, as needed, to ensure service providers are qualified to provide HCBS-AMH services in accordance with state and federal laws and regulations); and to ensure the individual’s safety and security. Electronic Visit Verification System. The state will demonstrate compliance with the Electronic Visit Verification System (EVV) requirements for personal care services (PCS) on or before January 1, 2021 and compliance with home health services by January 1, 2023 in accordance with section 12006 of the 21st Century CURES Act. Additional needs-based criteria for receiving the service, if applicable (specify): Specify limits (if any) on the amount, duration, or scope of this service. Per 42 CFR Section 440.240, services available to any categorically needy recipient cannot be less in amount, duration and scope than those services available to a medically needy recipient, and services must be equal for any individual within a group. States must also separately address standard state plan service questions related to sufficiency of services. (Choose each that applies): 俶䢢 Categorically needy (specify limits): Individuals receiving adult foster care or Department of Family and Protective Services foster care services may not also receive Supported Home Living services. Texas ensures duplication of services does not occur by prohibiting payment for services without authorization. Two entities may not be paid for providing the same service to the same individual during the same time period. This service may not be provided on the same day and at the same time as services that contain elements
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 51 §1915(i) State plan HCBS Approved: Supersedes:71 integral to the delivery of this service. Services that are provided by third parties must be coordinated with the Supported Home Living provider and through the recovery manager, including community-based rehabilitative services provided outside of the residence. Supported Home Living services should be provided only in settings within Texas, which meet home and community-based characteristic requirements for the type of residential support provided. Supported Home Living services cannot be provided in or on the grounds of the following settings: • Nursing facilities; • Institutions for mental disease; • Intermediate care facilities for individuals with Intellectual or Developmental Disabilities; • Inpatient hospitals; or • Any other location that has qualities of an institutional setting. Medically needy (specify limits): N/A Provider Qualifications (For each type of provider. Copy rows as needed): Provider Type (Specify): License (Specify): Certification (Specify): Other Standard (Specify): HCBS Provider agency that meets the minimum eligibility and standards for HCBS- AMH provider enrollment. HCBS provider agency enrolled and contracted with HHSC to provide HCBS services, which employs or has agreements with Supported Home Living Providers. Residential settings must meet relevant state and local requirements. Individual direct service providers must be at least 18 years of age. The employee provider must have a high school diploma or Certificate of High School Equivalency (GED credentials) or documentation of a proficiency evaluation of experience and competence to perform job tasks including ability to provide the required services as needed by the individual to be served as demonstrated through a written competency-based assessment. The individual provider must pass a criminal background check and also have at least three personal references from persons not related within three degrees of consanguinity that evidence the ability to provide a safe and healthy environment for the individual(s) to be served. Transportation of individuals must be provided in accordance with applicable state laws. Individuals transporting individuals must be 18 years of age or older; pass a criminal background check; and must have a valid driver's license and proof of insurance. Assisting with tasks delegated by an RN must be in accordance with state law. Individual providers of Supported Home Living services must complete initial and periodic training provided by HCBS provider
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 52 §1915(i) State plan HCBS Approved: Supersedes:71 agency which includes HHSC-required training in the HCBS-AMH program. Before entering into a provider agreement with the provider agency, HHSC verifies the providers’ compliance with these qualifications through a credentialing process. Contracted providers are obligated to verify on an ongoing basis that these qualifications are achieved, maintained, and documented in personnel files. HHSC will conduct annual review to verify these requirements continue to be met after the provider and HHSC enter into an agreement. Verification of Provider Qualifications (For each provider type listed above. Copy rows as needed): Provider Type (Specify): Entity Responsible for Verification (Specify): Frequency of Verification (Specify): HCBS Provider Agency that meets the minimum eligibility and standards for HCBS- AMH provider enrollment. HHSC Annual Service Delivery Method. (Check each that applies): Participant-directed 俶䢢Provider managed Service Specifications (Specify a service title for the HCBS listed in Attachment 4.19-B that the state plans to cover): Service Title: Respite Care Service Definition (Scope): Respite is a service that provides temporary relief from care giving to the primary caregiver of an individual during times when the individual's primary caregiver would normally provide care. In-home respite will be provided in the individual’s home or place of residence, or in the home of a family member or friend. Electronic Visit Verification System. The state will demonstrate compliance with the Electronic Visit Verification System (EVV) requirements for personal care services (PCS) on or before January 1, 2021 and compliance with home health services by January 1, 2023 in accordance with section 12006 of the 21st Century CURES Act. Respite is provided for the planned or emergency short-term relief for natural, unpaid caregivers. Respite is provided intermittently when the natural caregiver is temporarily unavailable to provide supports. This service provides an individual with personal assistance with activities of daily living (grooming, eating, bathing, dressing, and personal hygiene) and functional living tasks; assistance with planning and preparing meals; transportation or assistance in securing transportation; assistance with ambulation and mobility; reinforcement of rehabilitation or specialized therapies; assisting an individual with administration of certain medications or with supervision of self-medication in accordance with the Texas Board of Nursing rules as defined the Texas Administrative Code; and supervision as needed to ensure the individual’s health and safety. This service includes activities that facilitate the individual’s inclusion in community activities, use of natural supports and typical community services available to all people, social interaction, and participation in leisure activities, and development of socially valued behaviors and daily living and functional living skills. Respite is provided in the residence of the individual or in other locations, including residences in which supervised living or residential support is provided or in a respite facility that meets HHSC requirements and afford an environment
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 53 §1915(i) State plan HCBS Approved: Supersedes:71 that ensures the health, safety, comfort, and welfare of the individual. The provider of respite must ensure that respite is provided in accordance with the individual's recovery plan. Transportation costs associated with the respite service are included in the respite rate. Transportation to and from the respite service site is not a billable service for the respite service but is included in the billable service for supported home living. Out-of-home respite can be provided in the following locations: • Adult foster care home; • 24-hour residential habilitation home; • Licensed assisted living facilities; • Licensed Nursing Facilities. Additional needs-based criteria for receiving the service, if applicable (specify): Specify limits (if any) on the amount, duration, or scope of this service. Per 42 CFR Section 440.240, services available to any categorically needy recipient cannot be less in amount, duration and scope than those services available to a medically needy recipient, and services must be equal for any individual within a group. States must also separately address standard state plan service questions related to sufficiency of services. (Choose each that applies): 俶䢢 Categorically needy (specify limits): Reimbursement for respite is limited to 30 days annually of any combination of in-home or out-of-home respite. Other services indicated on the individual's recovery plan may be provided during the period of respite, if they are not duplicative of or integral to services which can be reimbursable as respite. Respite is not a reimbursable service for individuals receiving community-based residential supports in provider owned or operated settings, including host home/companion care, supervised living or assisted living; to relieve paid caregivers and providers or to supplant natural supports Payment of the cost of room and board is the responsibility of the individual except when the individual is receiving out-of-home respite services under HCBS-AMH. Room and board is included in the rate for out-of-home respite services. Medically needy (specify limits): N/A Provider Qualifications (For each type of provider. Copy rows as needed): Provider Type (Specify): License (Specify): Certification (Specify): Other Standard (Specify): HCBS Provider Agency that meets the minimum eligibility and standards for HCBS- AMH provider enrollment. HCBS provider agency enrolled and contracted with HHSC to provide HCBS services, which employs or contracts with individual respite workers. Respite settings must meet appropriate state and local licensure or certification requirements. Individual direct service workers must be 18 years of age or older; trained in CPR/first-aid; pass criminal history checks; not be on list of Employee Misconduct Registry or Nurse Aide Registry; maintain current Texas driver's license and proof of automobile insurance if transporting individuals; and be familiar with client-specific competencies. Before entering into a provider agreement
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 54 §1915(i) State plan HCBS Approved: Supersedes:71 with the provider agency, HHSC verifies the providers’ compliance with these qualifications through a credentialing process. Contracted providers are obligated to verify on an ongoing basis that these qualifications are achieved, maintained, and documented in personnel files. HHSC will conduct annual review to verify these requirements continue to be met after the provider and HHSC enter into an agreement. Verification of Provider Qualifications (For each provider type listed above. Copy rows as needed): Provider Type (Specify): Entity Responsible for Verification (Specify): Frequency of Verification (Specify): HCBS Provider Agency HHSC Annual Service Delivery Method. (Check each that applies): Participant-directed 俶䢢Provider managed Service Specifications (Specify a service title for the HCBS listed in Attachment 4.19-B that the state plans to cover): Service Title: Home Delivered Meals Service Definition (Scope): Home delivered meals services provide a nutritionally sound meal to individuals. Each meal provides a minimum of one-third of the current recommended dietary allowance (RDA) for the individual as adopted by the United States Department of Agriculture. The meal is delivered to the participant’s home. Home delivered meals do not constitute a full nutritional regimen. Additional needs-based criteria for receiving the service, if applicable (specify): Specify limits (if any) on the amount, duration, or scope of this service. Per 42 CFR Section 440.240, services available to any categorically needy recipient cannot be less in amount, duration and scope than those services available to a medically needy recipient, and services must be equal for any individual within a group. States must also separately address standard state plan service questions related to sufficiency of services. (Choose each that applies): 俶䢢 Categorically needy (specify limits): The provision of home delivered meals does not provide a full nutritional regimen (i.e., 3 meals a day). Medically needy (specify limits): N/A Provider Qualifications (For each type of provider. Copy rows as needed): Provider Type (Specify): License (Specify): Certification (Specify): Other Standard (Specify): HCBS Provider Agency that meets the minimum eligibility and standards for HCBS- AMH provider enrollment. HCBS-AMH provider agency enrolled and contracted with HHSC to provide HCBS- AMH services, which employs or contracts with home-delivered meal providers. An individual home delivered meals provider must follow procedures and maintain facilities that comply with all applicable state and local laws and regulations related to fire,
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 55 §1915(i) State plan HCBS Approved: Supersedes:71 health, sanitation, and safety; and food preparation, handling, and service activities. Before entering into a provider agreement with the provider agency, HHSC verifies the providers’ compliance with these qualifications through a credentialing process. Contracted providers are obligated to verify on an ongoing basis that these qualifications are achieved, maintained, and documented in personnel files. HHSC will conduct annual review to verify these requirements continue to be met after the provider and HHSC enter into an agreement. Verification of Provider Qualifications (For each provider type listed above. Copy rows as needed): Provider Type (Specify): Entity Responsible for Verification (Specify): Frequency of Verification (Specify): HCBS Provider Agency that meets the minimum eligibility and standards for HCBS- AMH provider enrollment. HHSC Annual Service Delivery Method. (Check each that applies): Participant-directed 俶䢢Provider managed Service Specifications (Specify a service title for the HCBS listed in Attachment 4.19-B that the state plans to cover): Service Title: Minor Home Modifications Service Definition (Scope): Minor home modifications are those physical adaptations to an individual’s home that are necessary to ensure the individual’s health, welfare, and safety, or that enable the individual to function with greater independence in the home. In order to receive minor home modifications under this program, the individual would require institutionalization without these adaptations. Adaptations may include widening of doorways, modification of bathroom facilities, installation of ramps, or other minor modifications which are necessary to achieve a specific rehabilitative goal defined in the IRP and prior approved by HHSC. Adaptations or improvements to the home that are of general utility and are not of direct medical or remedial benefit to the individual, such as carpeting, roof repair, central air conditioning, etc. are excluded from minor home modifications. Adaptations that add to the total square footage of the home are excluded from this benefit. Minor home modifications are not made to residential settings that are leased, owned, or controlled by service providers. All minor home modifications are provided in accordance with applicable state or local building codes. Additional needs-based criteria for receiving the service, if applicable (specify): The minor home modifications must be necessary to address specific functional limitations documented in the individual’s recovery plan and must be approved by HHSC. Specify limits (if any) on the amount, duration, or scope of this service. Per 42 CFR Section 440.240, services available to any categorically needy recipient cannot be less in amount, duration and scope than those services available to a medically needy recipient, and services must be equal for any individual within a group. States must also separately address standard state plan service questions related to sufficiency of services. (Choose each that applies): 俶䢢 Categorically needy (specify limits): There is an individual limit of $7,500.00 per lifetime for minor home modifications. Once that maximum
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 56 §1915(i) State plan HCBS Approved: Supersedes:71 is reached, $300 per service plan year per individual will be allowed for repair, replacement, or updating of existing modifications. The agency is responsible for obtaining cost-effective modifications authorized on the individual's plan. Should an individual require environmental modifications after the cost cap has been reached, the service planning team will assist the individual/family to access any other resources or alternate funding sources. Requests for exceptions will be evaluated on a case-by-case basis, including evaluation of need and exhaustion of all other means of obtaining the necessary minor home modification. Medically needy (specify limits): N/A Provider Qualifications (For each type of provider. Copy rows as needed): Provider Type (Specify): License (Specify): Certification (Specify): Other Standard (Specify): HCBS provider agency that meets the minimum eligibility and standards for HCBS- AMH provider enrollment. HCBS provider agency enrolled and contracted with HHSC to provide HCBS services. The agency must comply with the requirements for delivery of minor home modifications, which include requirements as to type of allowed modifications, time frames for completion, specifications for the modification, inspections of modifications, and follow-up on the completion of the modification. Individual providers must meet applicable laws and regulations for the provision of the approved minor home modification and provide modifications in accordance with applicable state and local building codes. Qualified building contractors provide minor home modifications in accordance with state and local building codes and other applicable regulations. Verification of Provider Qualifications (For each provider type listed above. Copy rows as needed): Provider Type (Specify): Entity Responsible for Verification (Specify): Frequency of Verification (Specify): HCBS provider agency that meets the minimum eligibility and standards for HCBS- AMH provider enrollment. HHSC Annual Service Delivery Method. (Check each that applies): Participant-directed 俶䢢Provider managed Service Specifications (Specify a service title for the HCBS listed in Attachment 4.19-B that the state plans to cover): Service Title: Nursing Service Definition (Scope):
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 57 §1915(i) State plan HCBS Approved: Supersedes:71 Nursing services are those services that are within the scope of the Texas Nurse Practice Act and are provided by an RN (or licensed vocational nurse under the supervision of an RN), licensed to practice in the state. Services cover ongoing chronic conditions such as wound care, medication administration (including training, monitoring, and evaluation of side effects), and supervising delegated tasks. This broadens the scope of these services beyond state plan services. Nursing services provide treatment and monitoring of health care procedures prescribed by a physician/medical practitioner, or as required by standards of professional practice or state law to be performed by licensed nursing personnel. This 1915(i) service is only provided to individuals age 21 and over. All medically necessary nursing services for children under age 21 are covered in the state plan pursuant to the EPSDT benefit. Additional needs-based criteria for receiving the service, if applicable (specify): Specify limits (if any) on the amount, duration, or scope of this service. Per 42 CFR Section 440.240, services available to any categorically needy recipient cannot be less in amount, duration and scope than those services available to a medically needy recipient, and services must be equal for any individual within a group. States must also separately address standard state plan service questions related to sufficiency of services. (Choose each that applies): 俶䢢 Categorically needy (specify limits): Nursing services are provided only after benefits available through Medicare, Medicaid, or other third party resources have been exhausted or are not applicable, including home health benefits. Medically needy (specify limits): N/A Provider Qualifications (For each type of provider. Copy rows as needed): Provider Type (Specify): License (Specify): Certification (Specify): Other Standard (Specify): HCBS provider agency that meets the minimum eligibility and standards for HCBS- AMH provider enrollment. RN (or licensed vocational nurse under the supervision of a registered nurse), licensed to practice in the state. HCBS provider agency enrolled and contracted with HHSC to provide HCBS services, which employs or contracts with nursing providers. An individual service provider must be an RN (or licensed vocational nurse under the supervision of a registered nurse), licensed to practice in the state or otherwise authorized to practice in Texas under the Nurse Licensure Compact. Nurses providing this service must comply with the requirements for delivery of nursing services, which include requirements such as compliance with the Texas Nurse Practice Act and delegation of nursing tasks. Verification of Provider Qualifications (For each provider type listed above. Copy rows as needed): Provider Type (Specify): Entity Responsible for Verification (Specify): Frequency of Verification (Specify): HCBS provider agency that meets the minimum eligibility and standards for HCBS- AMH provider HHSC Annual
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 58 §1915(i) State plan HCBS Approved: Supersedes:71SDJH enrollment. Nurse HCBS Provider agency Annual Service Delivery Method. (Check each that applies): Participant-directed 俶䢢Provider managed Service Specifications (Specify a service title for the HCBS listed in Attachment 4.19-B that the state plans to cover): Service Title: Substance Use Disorder (SUD) Services (abuse and dependence) Service Definition (Scope): Substance Use Disorder (SUD) services are assessment and ambulatory group and individual counseling for substance use disorders. Services are specialized to meet the needs of individuals who have experienced extended institutional placement. Providers must follow evidence-based or evidence-informed treatment modalities approved by HHSC. Services may be provided in the individual’s home or other community-based setting. Individuals must exhaust other state plan SUD benefits before choosing the HCBS SUD benefit unless other state plan benefits are not appropriate to meet the individual’s needs, limitations, and recovery goals as determined by the independent evaluation (e.g. severe cognitive or social functioning limitations, or a mental disability). Services are designed to assist the individual in achieving specific recovery goals identified in the IRP and in preventing relapse. Services are also designed to respect the individual’s culture, while addressing attitudinal and behavioral challenges that may impede the individual from realizing their desired recovery goals. Therapeutic modalities may include motivational interviewing; individual, group, and family counseling; psycho-education; medication management; harm reduction; and relapse-prevention. SUD treatment plans will be developed with active participation of the individual to specifically address and accommodate the individual’s needs, goals, and preferences and will support the overall HCBS recovery goals. Services will be provided using a team approach which integrates other HCBS services, such as peer support as appropriate to the individual’s needs and preferences. This 1915(i) service is only provided to individuals age 21 and over. All medically necessary SUD services for children under age 21 are covered in the state plan pursuant to the EPSDT benefit. Additional needs-based criteria for receiving the service, if applicable (specify): Specify limits (if any) on the amount, duration, or scope of this service. Per 42 CFR Section 440.240, services available to any categorically needy recipient cannot be less in amount, duration and scope than those services available to a medically needy recipient, and services must be equal for any individual within a group. States must also separately address standard state plan service questions related to sufficiency of services. (Choose each that applies): 俶䢢 Categorically needy (specify limits): This service may not be provided on the same day and at the same time as state plan SUD services. Medically needy (specify limits): N/A Provider Qualifications (For each type of provider. Copy rows as needed): Provider Type (Specify): License (Specify): Certification (Specify): Other Standard (Specify): HCBS provider agency that meets the minimum eligibility and standards for HCBS- AMH provider enrollment, which employs or contracts Individual counselors providing the SUD service must be Qualified Credentialed Counselors If the HCBS provider contracts with SUD treatment programs, these programs must be licensed by the Texas Department of State Health Services as Chemical Dependency Treatment Programs. Individual providers must be licensed and/or appropriately credentialed to provide services
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 59 §1915(i) State plan HCBS Approved: Supersedes:71 and directly supervises Licensed Chemical Dependency Treatment providers (QCCs) as defined by HHSC. SUD treatment programs must be licensed by the Texas Department of State Health Services as Chemical Dependency Treatment Programs. and act within the scope of their licensure and/or credentialing. Before entering into a provider agreement with the provider agency, HHSC verifies the providers’ compliance with these qualifications through a credentialing process. Contracted providers are obligated to verify on an ongoing basis that these qualifications are achieved, maintained, and documented in personnel files. HHSC will conduct annual review to verify these requirements continue to be met after the provider and HHSC enter into an agreement. Verification of Provider Qualifications (For each provider type listed above. Copy rows as needed): Provider Type (Specify): Entity Responsible for Verification (Specify): Frequency of Verification (Specify): HCBS provider agency that meets the minimum eligibility and standards for HCBS- AMH provider enrollment. HHSC Annual Service Delivery Method. (Check each that applies): Participant-directed 俶䢢Provider managed Service Specifications (Specify a service title for the HCBS listed in Attachment 4.19-B that the state plans to cover): Service Title: HCBS – AMH Recovery Management Service Definition (Scope): Service Definition (Scope): Recovery Management includes services assisting beneficiaries in gaining access to needed Medicaid State Plan and HCBS services, as well as medical, social, educational, and other resources, regardless of funding source. Recovery Managers are responsible for monitoring the provision of services included in the IRP to ensure that the individual’s needs, preferences, health, and welfare are promoted. The recovery manager: • Coordinates / leads development of the IRP using a person-centered planning approach which supports the individual in directing and making informed choices according to the individual’s needs and preferences; • Provides supporting documentation to be considered by HHSC in the independent evaluation and reevaluations; • Identifies services / providers, brokers to obtain and integrate services, facilitates, and advocates to resolve issues that impede access to needed services; • Develops / pursues resources to support the individual’s recovery goals including non-HCBS Medicaid, Medicare, and/or private insurance or other community resources; • Assists the individual in identifying and developing natural supports (family, friends, and other community members) and resources to promote the individual’s recovery; • Informs consumers of fair hearing rights; • Assists HCBS-AMH consumers with fair hearing requests when needed and upon request; • Educates and informs individuals about services, the individual recovery planning process, recovery resources, rights, and responsibilities; • Actively coordinates with other individuals and/or entities essential to physical and/or behavioral services for the individual (including the individual’s MCO) to ensure that other services are integrated and support the individual’s recovery goals, health, and welfare;
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 60 §1915(i) State plan HCBS Approved: Supersedes:71 • Monitors health, welfare, and safety through regular contacts (visits with the individual, paid and unpaid supports, and natural supports) at a minimum frequency required by HHSC; • Responds to and assesses emergency situations and incidents and assures that appropriate actions are taken to protect the health, welfare, and safety of individuals; • Reviews provider service documentation and monitors the individual’s progress; • Initiates recovery plan team discussions or meetings when services are not achieving desired outcomes. Outcomes include housing status, employment status, involvement in the criminal justice system, response to treatment and other services, and satisfaction with services; and • Through the recovery plan monitoring process, solicits input from consumer and/or family, as appropriate, related to satisfaction with services. In the performance of the monitoring function, the recovery manager will: • Arrange for modifications in services and service delivery, as necessary; • Advocate for continuity of services, system flexibility and integration, proper utilization of facilities and resources, accessibility, and beneficiary rights; and • Participate in any HHSC-identified activities related to quality oversight and provide reporting as required by HHSC. Recovery management includes functions necessary to facilitate community transition for beneficiaries who receive Medicaid-funded institutional services (e.g., Institutions for Mental Disease). Recovery management activities for individuals leaving institutions must be coordinated with, and must not duplicate, institutional discharge planning. This service may be provided up to 180 days in advance of anticipated movement to the community. The maximum caseload for a recovery manager providing services through HCBS-AMH is set by HHSC, and includes individuals in other waiver or state plan programs and other funding sources, unless the requirement is waived by HHSC. Services must be delivered in a manner that supports the consumer’s communication needs, including age- appropriate communication and translation services for beneficiaries that are of limited-English proficiency or who have other communication needs requiring translation assistance. Additional needs-based criteria for receiving the service, if applicable (specify): Specify limits (if any) on the amount, duration, or scope of this service. Per 42 CFR Section 440.240, services available to any categorically needy recipient cannot be less in amount, duration and scope than those services available to a medically needy recipient, and services must be equal for any individual within a group. States must also separately address standard state plan service questions related to sufficiency of services. (Choose each that applies): 俶䢢 Categorically needy (specify limits): The following activities are excluded from recovery management as a billable HCBS-AMH service: • Travel time incurred by the recovery manager may not be billed as a discrete unit of service; • Services that constitute the administration of another program such as child welfare or child protective services, parole and probation functions, legal services, public guardianship, special education, and foster care; and • Representative payee functions. Recovery management may only be provided by agencies and individuals employed by agencies who are not: • Related by blood or marriage to the consumer; • Financially or legally responsible for the consumer; • Empowered to make financial or health-related decisions on behalf of the consumer; or • Providers of HCBS-AMH for the individual, or those who have interest in or are employed by a provider of HCBS-AMH on the IRP, except when the provider is the only willing and qualified entity in a geographic area whom the individual consumer chooses to provide the service (provider of last resort)
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 61 §1915(i) State plan HCBS Approved: Supersedes:71 The Recovery Manager is responsible for coordination of services, including coordinating HCBS-AMH services, coordinating with the MCO that is providing other Medicaid services, and coordinating services provided by third parties. Recovery management providers will coordinate with the individual’s MCO to assure that other case management services are not being provided to the individual. The State will periodically review claims data in search of duplicative claims and adjust system edits accordingly, and when claims processing is automated through MMIS, system edits will prevent processing of duplicative claims. HHSC will enroll HCBS-AMH Provider Agencies and Recovery Management entities through separate Open Enrollments and will actively recruit both types of entities. Due to enormous geographic area of Texas and mental health professional shortages in the state (especially rural and frontier areas), Texas anticipates that some service areas may not have separate Provider Agencies and Recovery Management Entities that meet requirements of the program and provider agreement. In lieu of denying an individual life in his/her community of choice due to lack of available Provider Agencies and Recovery Management Entities, the State foresees that in this circumstance an HCBS provider of last resort may also provide recovery management services with certain conflict of interest protections in place. When an HCBS provider of last resort also provides recovery management services, HHSC will require a clear separation of provider and recovery management functions. The distinct individual staff providing recovery management must be administratively separate from other HCBS-AMH provider functions and any related utilization review units and functions. Recovery Managers who work for provider agencies that are providing other HCBS-AMH services as the provider of last resort will not be providers of any other HCBS-AMH service on the IRP. HHSC reviews the administrative structure of the HCBS-AMH agency to ensure that there is a clear administrative separation of recovery management and HCBS-AMH provider staff/functions before approving a provider to serve as a recovery manager, and periodically reviews (including unannounced site-reviews) the individuals performing recovery management to ensure that they are not providers of HCBS-AMH and not under the administrative control of units providing HCBS-AMH services. HHSC will also review resulting IRPs to ensure that there is no conflict of interest. This service may not be provided on the same day and at the same time as services that contain elements integral to the delivery of this service. Recovery management functions necessary to facilitate community transition may not be billed under TAS. Medically needy (specify limits): N/A Provider Qualifications (For each type of provider. Copy rows as needed): Provider Type (Specify): License (Specify): Certification (Specify): Other Standard (Specify): Recovery management provider enrolled and contracted with HHSC to provide recovery management services, or a recovery management entity which employs or contracts with individual recovery management providers Individual providers of recovery management must: • Have at least 2 years of experience working with people with severe mental illness; • Have a master’s degree in human services or a related field(the requirement to have a master’s degree may be waived by HHSC if HHSC determines that waiver is necessary to provide access to care to Medicaid recipients); • Demonstrate knowledge of issues affecting people with severe mental illness and community-based interventions/resources for this population; and • Complete HHSC-required training in the HCBS-AMH program.
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 62 §1915(i) State plan HCBS Approved: Supersedes:71 Verification of Provider Qualifications (For each provider type listed above. Copy rows as needed): Provider Type (Specify): Entity Responsible for Verification (Specify): Frequency of Verification (Specify): HCBS provider agency that meets the minimum eligibility and standards for HCBS- AMH provider enrollment. HHSC Annual Service Delivery Method. (Check each that applies): Participant-directed 俶䢢Provider managed
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 63 §1915(i) State plan HCBS Approved: Supersedes:71 2. 伪 Policies Concerning Payment for State plan HCBS Furnished by Relatives, Legally Responsible Individuals, and Legal Guardians. (By checking this box the state assures that): There are policies pertaining to payment the state makes to qualified persons furnishing State plan HCBS, who are relatives of the individual. There are additional policies and controls if the state makes payment to qualified legally responsible individuals or legal guardians who provide State Plan HCBS. (Specify (a) who may be paid to provide State plan HCBS; (b) the specific State plan HCBS that can be provided; (c) how the state ensures that the provision of services by such persons is in the best interest of the individual; (d) the state’s strategies for ongoing monitoring of services provided by such persons; (e) the controls to ensure that payments are made only for services rendered; and (f) if legally responsible individuals may provide personal care or similar services, the policies to determine and ensure that the services are extraordinary (over and above that which would ordinarily be provided by a legally responsibleindividual): The State permits HCBS agencies to make payment to legally responsible individuals, legal guardians, and relatives for furnishing State Plan HCBS, only for Host Home services. A) relative other than a spouse; court appointed guardian; legally authorized representative B) Host Home/Companion Care C) Host Home/Companion Services are provided to meet the person’s needs as determined by an individualized assessment performed in accordance with HHSC. The services are coordinated within the context of the IRP which delineates how Host Home/Companion Care Services are intended to achieve the identified goals. D) HHSC reviews the authorized host home/companion setting on an ongoing basis to ensure that it is community-based, inclusive and meets federal and state HCBS setting requirements. HHSC staff conduct periodic reviews of residential services in all settings to include unannounced site visits to provider-owned or operated settings. If the monitoring suggests that a change in service is needed, an independent reassessment is conducted by HHSC, or its designee, to re-evaluate the participant to determine the appropriateness of the service in accordance with HHSC requirements. E) HCBS-AMH Provider must have written documentation to support a service claim for Host Home/Companion Care as outlined in the HCBS-AMH billing guidelines. HHSC shall monitor performance of program activities and conduct regular data verification via desk reviews. The processincludes comparing the scope, frequency, duration, and amount of authorized services reported on the IRP with services reported on the provider invoice. Billable services are subject to prior approval by HHSC and may be subject to periodic reviews to ensure fidelity with evidence-based practice.
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 64 §1915(i) State plan HCBS Approved: Supersedes:71 Definition: Participant-direction means self-direction of services per §1915(i)(1)(G)(iii). 1. Election of Participant-Direction. (Select one): }The state does not offer opportunity for participant-direction of State plan HCBS. {Every participant in State plan HCBS (or the participant’s representative) is afforded the opportunity to elect to direct services. Alternate service delivery methods are available for participants who decide not to direct their services. {Participants in State plan HCBS (or the participant’s representative) are afforded the opportunity to direct some or all of their services, subject to criteria specified by the state. (Specify criteria): 2. Description of Participant-Direction. (Provide an overview of the opportunities for participant- direction under the State plan HCBS, including: (a) the nature of the opportunities afforded; (b) how participants may take advantage of these opportunities; (c) the entities that support individuals who direct their services and the supports that they provide; and, (d) other relevant information about the approach to participant-direction): 3. Limited Implementation of Participant-Direction. (Participant direction is a mode of service delivery, not a Medicaid service, and so is not subject to state wideness requirements. Select one): {Participant direction is available in all geographic areas in which State plan HCBS are available. {Participant-direction is available only to individuals who reside in the following geographic areas or political subdivisions of the state. Individuals who reside in these areas may elect self-directed service delivery options offered by the state, or may choose instead to receive comparable services through the benefit’s standard service delivery methods that are in effect in all geographic areas in which State plan HCBS are available. (Specify the areas of the state affected by this option): 4. Participant-Directed Services. (Indicate the State plan HCBS that may be participant-directed and the authority offered for each. Add lines as required): Participant-Directed Service Employer Authority Budget Authority 5. Financial Management. (Select one) : Financial Management is not furnished. Standard Medicaid payment mechanisms are used. Financial Management is furnished as a Medicaid administrative activity necessary for administration of the Medicaid State plan. Participant-Direction of Services
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 65 §1915(i) State plan HCBS Approved: Supersedes:71SDJH 6. Participant–Directed Person-Centered Service Plan. (By checking this box the state assures that): Based on the independent assessment required under 42 CFR §441.720, the individualized person-centered service plan is developed jointly with the individual, meets federal requirements at 42 CFR §441.725, and: Specifies the State plan HCBS that the individual will be responsible for directing; Identifies the methods by which the individual will plan, direct or control services, including whether the individual will exercise authority over the employment of service providers and/or authority over expenditures from the individualized budget; Includes appropriate risk management techniques that explicitly recognize the roles and sharing of responsibilities in obtaining services in a self-directed manner and assures the appropriateness of this plan based upon the resources and support needs of the individual; Describes the process for facilitating voluntary and involuntary transition from self-direction including any circumstances under which transition out of self-direction is involuntary. There must be state procedures to ensure the continuity of services during the transition from self-direction to other service delivery methods; and Specifies the financial management supports to be provided. 7. Voluntary and Involuntary Termination of Participant-Direction. (Describe how the state facilitates an individual’s transition from participant-direction, and specify any circumstances when transition is involuntary): 8. Opportunities for Participant-Direction a. Participant–Employer Authority (individual can select, manage, and dismiss State plan HCBS providers). (Select one): The state does not offer opportunity for participant-employer authority. Participants may elect participant-employer Authority (Check each that applies): Participant/Co-Employer. The participant (or the participant’s representative) functions as the co-employer (managing employer) of workers who provide waiver services. An agency is the common law employer of participant-selected/recruited staff and performs necessary payroll and human resources functions. Supports are available to assist the participant in conducting employer-related functions. Participant/Common Law Employer. The participant (or the participant’s representative) is the common law employer of workers who provide waiver services. An IRS-approved Fiscal/Employer Agent functions as the participant’s agent in performing payroll and other employer responsibilities that are required by federal and state law. Supports are available to assist the participant in conducting employer-related functions. b. Participant–Budget Authority (individual directs a budget that does not result in payment for medical assistance to the individual). (Select one): The state does not offer opportunity for participants to direct a budget. Participants may elect Participant–Budget Authority. Participant-Directed Budget. (Describe in detail the method(s) that are used to establish the amount of the budget over which the participant has authority, including the method for calculating the dollar values in the budget based on reliable costs and service utilization, is applied consistently to each participant, and is adjusted to reflect changes in individual assessments and service plans. Information about these method(s) must be made publicly available and included in the person-centered service plan.):
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State: Texas TN:20-0003 Effective: September 1, 2020 State plan Attachment 3.1–i: Page 66 §1915(i) State plan HCBS Approved: Supersedes:71 Expenditure Safeguards. (Describe the safeguards that have been established for the timely prevention of the premature depletion of the participant-directed budget or to address potential service delivery problems that may be associated with budget underutilization and the entity (or entities) responsible for implementing these safeguards.
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State: Texas TN: 20-0003 Effective: September 1, 2020 State plan Attachment 3.1-i: Page 67 §1915(i) State plan HCBS Approved: Supersedes: 71 Quality Measures (Describe the state’s quality improvement strategy. For each requirement, and lettered sub-requirement, complete the table below): 1. Service plans a) address assessed needs of 1915(i) participants; b) are updated annually; and (c document choice of services and providers. 2. Eligibility Requirements: (a) an evaluation for 1915(i) State plan HCBS eligibility is provided to all applicants for whom there is reasonable indication that 1915(i) services may be needed in the future; (b) the processes and instruments described in the approved state plan for determining 1915(i) eligibility are applied appropriately; and (c) the 1915(i) benefit eligibility of enrolled individuals is reevaluated at least annually or if more frequent, as specified in the approved state plan for 1915(i) HCBS. 3. Providers meet required qualifications. 4. Settings meet the home and community-based setting requirements as specified in this SPA and in accordance with 42 CFR 441.710(a)(1) and (2). 5. The SMA retains authority and responsibility for program operations and oversight. 6. The SMA maintains financial accountability through payment of claims for services that are authorized and furnished to 1915(i) participants by qualified providers. 7. The state identifies, addresses, and seeks to prevent incidents of abuse, neglect, and exploitation, including the use of restraints. (Table repeats for each measure for each requirement and lettered sub-requirement above.) Requirement An evaluation for 1915(i) SPA eligibility is provided to all applicants for whom there is reasonable indication that services may needed in the future, The processes and instruments described in the approved 1915(i) SPA are applied appropriately and according to the approved description to determine if the needs-based criteria were met. and 1915(i) benefit eligibility of enrolled individuals is reevaluated at least annually or, if more frequent, as specified in the approved state plan for 1915(i) HCBS. Discovery Discovery Evidence (Performance Measure) 1. The number and percent of individuals that were determined to meet needs- based criteria requirements prior to receiving 1915(i) services. 2. The number and percent of individuals’ initial needs-based criteria determination forms/instruments that were completed, as required in the approved SPA. 3. The number and percent of individuals’ initial determinations, where level of need criteria was applied correctly. Discovery Activity (Source of Data & sample size) Record review, onsite; Representative sample with a confidence level of 95 percent. Monitoring Responsibilities (Agency or entity that conducts discoveryactivities) HHSC collects, generates, aggregates, and analyzes Quality Improvement Strategy
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State: Texas TN: 20-0003 Effective: September 1, 2020 State plan Attachment 3.1-i: Page 68 §1915(i) State plan HCBS Approved: Supersedes:71 Requirement An evaluation for 1915(i) SPA eligibility is provided to all applicants for whom there is reasonable indication that services may needed in the future, The processes and instruments described in the approved 1915(i) SPA are applied appropriately and according to the approved description to determine if the needs-based criteria were met. and 1915(i) benefit eligibility of enrolled individuals is reevaluated at least annually or, if more frequent, as specified in the approved state plan for 1915(i) HCBS. Frequency Annually Remediation Remediation Responsibilities (Who corrects, analyzes, and aggregates remediation activities; required timeframes for remediation) HHSC Frequency (of Analysis and Aggregation) Annually Requirement Service plans address assessed needs of 1915(i) participants, are updated annually, and document choice of services and providers. Discovery Discovery Evidence (Performance Measure) 1. Number and percent of participants with current individual recovery plans (IRPs) updated annually 2. Number and percent of participants with IRPs which document the individual’s choice among and between HCBS-AMH services. 3.Number and percent of participants with IRPs which document providers and individual goals consistent with their individual assessments. 4.Number and percent of participants with IRPs that address all members' assessed needs (including health and safety risk factors) and personal goals, either by the provision of HCBS services or through other means. 5.Number and percent of participants with services delivered in accordance with the IRP, including the type, scope, amount, duration, and frequency specified in the service plan. Discovery Activity (Source of Data & sample size) Record review, onsite; Representative sample with a confidence level of 95 percent. Monitoring Responsibilities (Agency or entity that conducts discoveryactivities) HHSC collects, generates, aggregates, and analyzes Requirement Service plans address assessed needs of 1915(i) participants, are updated annually, and document choice of services and providers. Frequency Annually Remediation
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State: Texas TN: 20-0003 Effective: September 1, 2020 State plan Attachment 3.1-i: Page 69 §1915(i) State plan HCBS Approved: Supersedes:71 Remediation Responsibilities (Who corrects, analyzes, and aggregates remediation activities; required timeframes for remediation) HHSC Frequency (of Analysis and Aggregation) Annually Requirement HCBS-AMH Provider Agencies and HCBS-AMH service providers meet required qualifications. HCBS-AMH Provider agencies must meet the minimum eligibility and standards for HCBS- AMH provider enrollment, which include: x Must have experience with and / or demonstrated capacity to administer services for people with severe mental illness or related populations x Must be a legal entity under state law, have the authority to do business in Texas, and be in good standing to do business in Texas and conduct the activities required by HHSC. x Must have a Texas address; and x Must have organizational policies and procedures acceptable to HHSC to deliver HCBS- AMH services Discovery Discovery Evidence (Performance Measure) 1.Number and percent of HCBS providers initially meeting licensure and certification requirements prior to furnishing HCBS services. 2. Number and percent of HCBS providers meeting licensure and certification requirements while furnishing services. 3. Number and percent of HCBS-AMH provider agencies with an active agreement with HHSC/HHSC. 4. Number and percent of HCBS providers who meet training requirements for delivering HCBS services. 5. Number and percent of enrolled HCBS providers serving HCBS clients (by provider type). Discovery Activity (Source of Data & sample size) Representative sample, with a confidence level of 95 percent, of provider agencies, open enrollment applications, provider agreements, state licensure authorities, and provider personnel records. Monitoring Responsibilities (Agency or entity that conducts discoveryactivities) HHSC collects, generates, aggregates, and analyzes Requirement HCBS-AMH Provider Agencies and HCBS-AMH service providers meet required qualifications. HCBS-AMH Provider agencies must meet the minimum eligibility and standards for HCBS- AMH provider enrollment, which include: x Must have experience with and / or demonstrated capacity to administer services for people with severe mental illness or related populations x Must be a legal entity under state law, have the authority to do business in Texas, and be in good standing to do business in Texas and conduct the activities required by HHSC. x Must have a Texas address; and x Must have organizational policies and procedures acceptable to HHSC to deliver HCBS-
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State: Texas TN: 20-0003 Effective: September 1, 2020 State plan Attachment 3.1-i: Page 70 §1915(i) State plan HCBS Approved: Supersedes:71 AMH services Frequency Annually Remediation Remediation Responsibilities (Who corrects, analyzes, and aggregates remediation activities; required timeframes for remediation) HHSC Frequency (of Analysis and Aggregation) Annually Requirement Settings meet the home and community-based setting requirements as specified in this SPA. Discovery Discovery Evidence (Performance Measure) 1. Number and percent of HCBS settings meeting appropriate licensure or certification and Federal HCBS requirements. Discovery Activity (Source of Data & sample size) Representative sample, with a confidence level of 95 percent, of provider agencies, on- site reviews, and report of recovery managers Monitoring Responsibilities (Agency or entity that conducts discoveryactivities) HHSC collects, generates, aggregates, and analyzes a representative sample, with a confidence level of 95 percent, of provider agencies, onsite reviews, and report of recovery managers of the number and percent of HCBS settings meeting appropriate licensure or certification and Federal HCBS requirements Requirement Settings meet the home and community-based setting requirements as specified in this SPA. Frequency Annually Remediation Remediation Responsibilities (Who corrects, analyzes, and aggregates remediation activities; required timeframes for remediation) HHSC Frequency (of Analysis and Aggregation) Annually
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State: Texas TN: 20-0003 Effective: September 1, 2020 State plan Attachment 3.1-i: Page 71 §1915(i) State plan HCBS Approved: Supersedes:71 Requirement The SMA retains authority and responsibility for program operations and oversight. Discovery Discovery Evidence (Performance Measure) 1.Number and percent of aggregated performance measure reports generated and reviewed by the State Medicaid Agency that contain discovery, remediation, and system improvements for ongoing compliance of the assurances. 2. Number and percent of state plan amendments, renewals, and financial reports approved by HHSC prior to implementation by HHSC. 3. Number and percent of SPA concepts and policies requiring MMIS programming approved by HHSC prior to the development of a formal implementation plan by HHSC. Discovery Activity (Source of Data & sample size) Reports to HHSC on delegated administrative functions; 100 percent sample size Monitoring Responsibilities (Agency or entity that conducts discoveryactivities) HHSC collects, generates, aggregates, analyzes Requirement The SMA retains authority and responsibility for program operations and oversight. Frequency Annually Remediation Remediation Responsibilities (Who corrects, analyzes, and aggregates remediation activities; required timeframes for remediation) HHSC Frequency (of Analysis and Aggregation) Annually Requirement HHSC maintains financial accountability through payment of claims for services that are authorized and furnished to 1915(i) participants by qualified providers. Discovery Discovery Evidence (Performance Measure) 1. Number and percent of providers that have payment recouped for HCBS services without supporting documentation. 2. Number and/or percent of claims verified through the HHSC compliance audit to have paid in accordance with the participant’s IRP. 3. Number and/or percentage of rates which remain consistent with the approved rate methodology throughout the five year SPA cycle. Discovery Activity (Source of Data & sample size) Routine claims verification audits; Representative sample, with confidence level of 95 percent of case managers. Annual review of rate setting methodology
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State: Texas TN: 20-0003 Effective: September 1, 2020 State plan Attachment 3.1-i: Page 72 §1915(i) State plan HCBS Approved: Supersedes:71 Monitoring Responsibilities (Agency or entity that conducts discoveryactivities) HHSC collects, generates, aggregates, and analyzes Requirement HHSC maintains financial accountability through payment of claims for services that are authorized and furnished to 1915(i) participants by qualified providers. Frequency Annually Remediation Remediation Responsibilities (Who corrects, analyzes, and aggregates remediation activities; required timeframes for remediation) HHSC Frequency (of Analysis and Aggregation) Annually Requirement The State identifies, addresses, and seeks to prevent incidents of abuse, neglect, and exploitation (ANE), including the use of restraints. Discovery Discovery Evidence (Performance Measure) 1. Number and/or percent of reports related to the abuse, neglect, exploitation, and unexplained deaths of participants where an investigation was completed within time frames established by State law. 2. Number and percent of participants who received information on how to report the suspected abuse, neglect, or exploitation of adults. 3. Number and percent of participants who received information regarding their rights to a state fair hearing via the official state form. 4. Number and percent of grievances filed by participants that were resolved within 14 calendar days according to approved SPA guidelines. 5. Number and percent of allegations of abuse, neglect, or exploitation investigated that were later substantiated, where recommended actions to protect health and welfare were implemented. 6. Number and percent of participants’ critical incidents related to ANE that were reported, initiated, reviewed, and completed within required timeframes as specified in the approved SPA. 7. Number and percent of unauthorized uses of restrictive interventions that were appropriately reported. 8. Number and percent of HCBS participants who received physical exams consistent with state 1915(i) policy. Discovery Activity (Source of Data & sample size) 100 percent sample, HHSC performance monitoring of reports related to abuse, neglect, exploitation, or unexplained deaths; critical incidents; reports of restrictive intervention application; and; reports of ANE by primary care or physical health providers. Monitoring Responsibilities (Agency or entity that conducts discoveryactivities) HHSC collects, generates, aggregates, and analyzes.
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State: Texas TN: 20-0003 Effective: September 1, 2020 State plan Attachment 3.1-i: Page 73 §1915(i) State plan HCBS Approved: Supersedes:71 Requirement The State identifies, addresses, and seeks to prevent incidents of abuse, neglect, and exploitation (ANE), including the use of restraints. Frequency Annually Remediation Remediation Responsibilities (Who corrects, analyzes, and aggregates remediation activities; required timeframes for remediation) HHSC Frequency (of Analysis and Aggregation) Annually System Improvement (Describe the process for systems improvement as a result of aggregated discovery and remediation activities.) 1. Methods for Analyzing Data and Prioritizing Need for System Improvement 2. Roles and Responsibilities 3. Frequency Program performance data • Track and trend system performance • Analyze discovery Quality management meetings • Assess system • changes • Focus on reporting • requirements and • refining reports Onsite reviews • Documentation review • Onsite interviews Corrective action plans (CAP) HHSC will collect, collate, review, and post. HHSC will review the data and have final direction over corrective action plans. HHSC will collect, analyze, and report. HHSC provides oversight and direction. HHSC coordinates and conducts onsite reviews. HHSC provides oversight and direction. Annually, HHSC [reviews] clinical operations (utilization management, quality management, care management, compliance with HCB settings requirements). Compliance issues will require the submission of a corrective action plan to HHSC for approval and ongoing monitoring. The provider shall be actively engaged in the development of the corrective action plan (CAP) to the satisfaction of the State. The CAP is monitored by HHSC-, which has final direction over the CAP. Areas for improvement will be monitored as per CAP and presented quarterly during Quality Management meetings and includes analysis of performance data and onsite review findings of program non-compliance follow-up.
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State: Texas TN: 20-0003 Effective: September 1, 2020 State plan Attachment 3.1-i: Page 74 §1915(i) State plan HCBS Approved: Supersedes:71 4. Method for Evaluating Effectiveness of System Changes x Program performance data - Updated monthly and reported quarterly x Quality management meetings – Quarterly meetings x Onsite reviews – Annually x Corrective action plans (CAP) - Areas for improvement will be monitored as per CAP and presented quarterly during Quality Management meetings x Program performance data o Set performance benchmarks o Review of service trends o Review program implementation o Track and trend system performance o Analyze the discovery; synthesize the data; o HHSC, with HHSC, will make corrective action plans regarding quality improvement (QI). o HHSC will review QI recommendations quarterly and build upon those improvements through continuous quality improvement. x Quality management meetings o Monitoring contract and HCBS compliance for service delivery o Review of clinical assessment client outcome measures x Onsite reviews o Review of clinical operations (utilization management, quality management, care management, compliance with HCB settings requirements) o Compliance issues will require the submission of a corrective action plan to HHSC for approval and ongoing monitoring. x Corrective action plans (CAP) - Areas for improvement will be monitored as per CAP and presented quarterly during Quality Management meetings o Analysis of performance data o Onsite review findings of program non- compliance follow-up
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State: Texas TN: 20-0003 Effective: September 1, 2020 §1915(i) State plan HCBS State plan Attachment 4.19–B 3DJH 6XSHUVHGHV71 Approved:
1. Services Provided Under Section 1915(i) of the Social Security Act. For each optional service, describe the methods and standards used to set the associated payment rate. (Check each that applies, and describe methods and standards to set rates): HCBS Case Management HCBS Homemaker HCBS Home Health Aide HCBS Personal Care HCBS Adult Day Health HCBS Habilitation 俶 HCBS Respite Care • The In-Home Respite rate is based on the Community Based Alternatives (CBA – terminated 9/1/2014) Medicaid Waiver program and the Community Living Assistance and Support Services (CLASS) Medicaid Waiver program rate. This rate is set using cost report data from both programs combined into a single array. Please see below for details on setting rates using cost report data and the rate setting process in general. • Out-of-Home Respite in a Nursing Facility rates are the State Plan Nursing Facility rates. These rates are set using cost report data. Please see below for details on setting rates using cost report data and the rate setting process in general. • The Out-of-Home Respite in a Licensed Assisted Living Facility rates are the CBA Assisted Living rates. These rates are set using cost report data. Please see below for details on setting rates using cost report data and the rate setting process in general. • The Out-of-Home Respite in a 24-hour Residential Habilitation Home rate is based on a weighted average of the Home and Community-based Services (HCS) Medicaid Waiver program Supervised Living Services rates. These rates are set using cost report data. Please see below for details on setting rates using cost report data and the rate setting process in general. • The Out-of-Home Respite in an Adult Foster Care home rates are the CBA Out-of-Home Respite in an Adult Foster Care home rates. These rates are determined by modeling the estimated amount of one-on- one time the adult foster care provider would provide to the individual multiplied by a reimbursement amount appropriate for the skill level of the caregiver providing the assistance. These rates are updated periodically for inflation. Please see below for information on the rate setting process in general. For Individuals with Chronic Mental Illness, the following services: HCBS Day Treatment or Other Partial Hospitalization Services 俶 HCBS Psychosocial Rehabilitation The rates for psychosocial rehabilitative services are based on the established State Plan Medicaid fee schedule. HCBS Clinic Services (whether or not furnished in a facility for CMI) Methods and Standards for Establishing Payment Rates
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State: Texas TN: 20-0003 Effective: September 1, 2020 §1915(i) State plan HCBS State plan Attachment 4.19–B: 3DJH Approved: Supersedes: 71 俶 Other Services (specify below) General Rate Setting The rates for all services in the HCBS-AMH program are available on the HHSC Rate Analysis Department’s website, as outlined on Attachment 4.19-B, Page 1. Unless otherwise specified, all rates are effective as of January 1, 2015. HHSC determines payment rates every two years for each service. The rates for services are prospective and uniform statewide. HHSC determines payment rates after analysis of financial and statistical information, and the effect of the payment rates on the achievement of program objectives, including economic conditions and budgetary considerations. Payment rates are developed as described below. Cost Reports The rates for certain services are set using cost report data. Providers of these services are required to submit annual cost reports to HHSC. Providers are responsible for eliminating all unallowable expenses from the cost report prior to submission of the cost report. HHSC reviews all cost reports and a sample of cost reports are reviewed on-site. HHSC removes any unallowable costs and corrects any errors detected on the cost report in the course of the review or on-site audit. Audited cost reports are used in the determination of statewide prospective rates. The recommended unit of service rates for each service are determined as follows: (1) total allowable costs for each provider are determined from the audited cost report; (2) each provider’s total allowable costs are projected from the historical cost reporting period to the prospective reimbursement period using the appropriate inflationary factors outlined below; (3) payroll taxes and benefits are allocated to each salary item; (4) total projected allowable costs are divided by the number of units of service to determine the projected cost per unit of service; (5) the allowable costs per unit of service for each contracted provider are arrayed and weighted by the number of units of service and the median cost per unit of service is calculated; and (6) the median cost per unit of service for each service is multiplied by 1.044. Additionally for the HCS and TxHmL programs, the initial model-based rates for these services were determined using cost, financial, statistical, and operational information collected during site visits performed by an independent consultant. The data was collected from cost reports and the service providers' accounting systems. Additionally, the state fiscal year (SFY) 1996 state wage data, the SFY 1994 cost data, and the SFY 1995 data from service providers was reviewed and analyzed. The base model rate year was calendar year 1997. Data from SFY 1994-1996 were used to develop the current rate structure; rates are rebased every biennium from the most recent projected cost report data, within available appropriations. In order to project costs to the prospective reimbursement period, HHSC uses the Personal Consumption Expenditures (PCE) chain-type price index as the general cost inflation index. The PCE chain-type price index is a nationally recognized measure of inflation published by the Bureau of Economic Analysis of the U.S. Department of Commerce. To project or inflate costs from the reporting period to the prospective reimbursement period, HHSC uses the lowest feasible PCE chain-type price index forecast consistent with the forecasts of nationally recognized sources available to HHSC at the time proposed reimbursement is prepared for public dissemination and comment. HHSC uses specific indices in place of the general cost inflation index when appropriate item-specific or program-specific cost indices are available from cost reports or other surveys, other Texas state agencies or independent private sources, or nationally recognized public agencies or independent private firms, and HHSC have determined that these specific indices are derived from information that adequately represents the program(s) or cost(s) to which the specific index is to be applied. Nursing wages are inflated by wage inflation factors based on wage and hour survey information submitted on cost reports or special surveys, Social Security payroll taxes are inflated by FICA inflation factors based on data obtained from the Statistical Abstract of the United States, and federal and state unemployment taxes are inflated by FUTA/SUTA inflation factors based on data obtained from the Texas Workforce Commission. Arrayed rates are determined by combining all costs from programs with sufficient reliable cost report data into a single array. The rate methodology is then applied to this array to determine a reimbursement rate. The following rates are set based on cost reports: The Host Home/Companion Care, Supervised Living Services and Supported Home Living rates are based on the HCS rates, and the Assisted Living Services rate is based on the CBA Assisted Living rate. These rates are set using cost report data. Please see below for details on setting rates using cost report data and the rate setting process in general.
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State: Texas TN: 20-0003 Effective: September 1, 2020 §1915(i) State plan HCBS State plan Attachment 4.19–B: 3DJH Approved: Supersedes:71 The Supported Employment and Employment Assistance rates are based on the CLASS, Deaf Blind with Multiple Disabilities (DBMD) Medicaid Waiver program, HCS, and Texas Home Living (TxHmL) Medicaid Waiver program rates. These rates are set using cost report data from these programs combined into a single array. Please see below for details on setting rates using cost report data and the rate setting process in general. The Nursing Services rates are based on the CBA, CLASS, DBMD, HCS, Medically Dependent Children Program (MDCP), and TxHmL rates. These rates are set using cost report data from these programs combined into a single array. Please see below for details on setting rates using cost report data and the rate setting process in general. The Community Psychiatric Supports and Treatment rate is based on the Behavioral Support Services rate in the CLASS, DBMD, HCS, and TxHmL programs. This rate is set using cost report data from these programs combined into a single array. Please see below for details on setting rates using cost report data and the rate setting process in general. Modeled Rates If payment rates are not available from other programs that provide similar services, or when historical costs are unavailable, such as in the case of a new program, payment rates are determined using a pro- forma analysis in accordance with Title 1 of the Texas Administrative Code (TAC) § 355.105(h) (relating to General Reporting and Documentation Requirements, Methods, and Procedures). A pro-forma analysis is defined as an item-by-item, or classes-of-items, calculation of the reasonable and necessary expenses for a provider to operate. The analysis may involve assumptions about the salary of an administrator or program director, staff salaries, employee benefits and payroll taxes, building depreciation, mortgage interest, contracted client care expenses, and other building or administration expenses. To determine the cost per unit of service, HHSC adds all the pro-forma expenses and divides the total by the estimated number of units of service that a fully operational provider is likely to provide. The pro-forma analysis is based on available information that is determined to be sufficient, accurate, and reliable by HHSC, including valid cost report data and survey data. Pro-forma rate setting involves using historical costs of delivering similar services, where appropriate data are available, and estimating the basic types and costs of products and services necessary to deliver services meeting federal and state requirements. The pro-forma analysis is conducted in a way that ensures that the resultant reimbursements are sufficient to support the requirements of the contracted program. When HHSC staff determine that sufficient and reliable cost report data have become available, the pro-forma reimbursement determination may be replaced with a process based on cost reports. The following rates are modeled using a pro-forma analysis: The rate for Transition Assistance Services is a one-time payment for the procurement of items and services the participant needs to move from an institution, a provider-operated setting, or family home to their own private community residence. The rate is determined by modeling the estimated salary for a person with the necessary skills and training, the estimated time spent with the participant, and the procurement of the necessary goods and services. The salary and time estimates were based upon the experience of providers delivering similar services under a different program. This rate is updated periodically for inflation. Non-Medical Transportation is paid at the rate set by the Texas Comptroller of Public Accounts. The Texas Comptroller adopts the maximum mileage rate established by the IRS for personal income tax purposes. The home delivered meals rate is a cost limit, established at the 80th percentile of provider costs using cost report data submitted by providers of service. Peer support rates are modeled based on the estimated salary for a person with the necessary skills and training to provide peer support. Adaptive Aids, Vehicular Modification, and Minor Home Modifications rates are at cost. The rates for Substance Abuse Disorder services and HCBS – Adult Mental Health Recovery Management are based on the established State Plan Medicaid fee schedule.
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State: Texas TN: 20-0003 Effective: September 1, 2020 §1915(i) State plan HCBS State plan Attachment 2.2-A: 3DJHL Approved: Supersedes:71 Optional Groups other than the Medically Needy In addition to providing State plan HCBS to individuals described in 1915(i)(1), the state may also cover the optional categorically needy eligibility group of individuals described in 1902(a)(10)(A)(ii)(XXII) who are eligible for HCBS under the needs-based criteria established under 1915(i)(1)(A) and have income that does not exceed 150% of the FPL, or who are eligible for HCBS under a waiver approved for the state under Section 1915(c), (d) or (e) or Section 1115 (even if they are not receiving such services), and who do not have income that exceeds 300% of the supplemental security income benefit rate. See 42 CFR § 435.219. (Select one): 伪䢢 No. Does not apply. State does not cover optional categorically needy groups. Yes. State covers the following optional categorically needy groups. (Select all that apply): (a) Individuals not otherwise eligible for Medicaid who meet the needs-based criteria of the 1915(i) benefit, have income that does not exceed 150% of the federal poverty level, and will receive 1915(i) services. There is no resource test for this group. Methodology used: (Select one): SSI. The state uses the following less restrictive 1902(r)(2) income disregards for this group. (Describe, if any): OTHER (describe): (b) Individuals who are eligible for home and community-based services under a waiver approved for the State under section 1915(c), (d) or (e) (even if they are not receiving such services), and who do not have income that exceeds 300% of the supplemental security income benefit rate. Income limit: (Select one): 300% of the SSI/FBR Less than 300% of the SSI/FBR (Specify): % Groups Covered
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State: Texas TN: 20-0003 Effective: September 1, 2020 §1915(i) State plan HCBS State plan Attachment 2.2-A: 3DJHM Approved: Supersedes:71 Specify the applicable 1915(c), (d), or (e) waiver or waivers for which these individuals would be eligible: (Specify waiver name(s) and number(s)): (c) Individuals eligible for 1915(c), (d) or (e) -like services under an approved 1115 waiver. The income and resource standards and methodologies are the same as the applicable approved 1115 waiver. Specify the 1115 waiver demonstration or demonstrations for which these individuals would be eligible. (Specify demonstration name(s) and number(s)): PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to average 114 hours per response, including the time to review instructions, search existing data resources, and gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26- 05, and Baltimore, Maryland 21244-1850.
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State: Texas §1915(i) State plan HCBS Attachment 2.2A Page 23.k TN: 20-0003 Supersedes: TN: 14-0014 Approval Date: Effective Date: RESERVED FOR FUTURE USE
(spa)(tx-20-0006)(approval-document)Texas Medicaid SPA TX-20-0006: Approval Document (approved June 17, 2020, effective January 1, 2020)#
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Table of Contents State/Territory Name: Texas State Plan Amendment (SPA) #: 20-0006 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form 3) Approved Page
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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Center for Medicaid & CHIP Services 233 North Michigan Ave., Suite 600 Chicago, Illinois 60601 Financial Management Group Ms. Stephanie Stephens State Medicaid/CHIP Director Health and Human Services Commission Mail Code: H100 Post Office Box 13247 Austin, Texas 78711 RE: Texas TN 20-0005 Dear Ms. Stephens: We have reviewed the proposed Texas State Plan Amendment (SPA) to Attachment 4.19-B, TX#20- 0005, which was submitted to the Centers for Medicare & Medicaid Services (CMS) on March 31, 2020. This state plan amendment updates the clinical laboratory services page of the State Plan as a result of the 2020 calendar year fee review of clinical diagnostic laboratory services. Based upon the information provided by the State, we have approved the amendment with an effective date of January 1, 2020. We are enclosing the approved CMS-179 and a copy of the new state plan page. If you have any additional questions or need further assistance, please contact Tamara Sampson at 214-767-6431 or Tamara.Sampson@cms.hhs.gov. Sincerely, Todd McMillion Director Division of Reimbursement Review Enclosures June 17, 2020
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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES FORM APPROVED 0MB NO. 0938-0193 1. TRANSMITTAL NUMBER: 2. STATE: TRANSMITTAL AND NOTICE OF APPROVAL OF TEXAS STATE PLAN MATERIAL 20-0005 FOR: CENTERS FOR MEDICARE AND MEDICAID SERVICES 3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE: CENTERS FOR MEDICARE AND MEDICAID SERVICES 1 1 2020 DEPARTMENT OF HEALTH AND HUMAN SERVICES anuary 5. TYPE OF PLAN MATERIAL (Circle One): 1J NEW STATE PLAN El AMENDMENT TO BE CONSIDERED AS NEW PLAN AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment) 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMPACT: SEE ATTACHMENT a. FFY 2020 $23,538 Social Security Act §1902(a)(30); 42 CFR §447.201(b) 8. PAGE NUMBER OF THE PLAN SECTION OR 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION ATTACHM ENT: OR ATTACHMENT (If Applicable): SEE ATTACHMENT TO BLOCKS 8 & 9 SEE ATTACHMENT TO BLOCKS 8 & 9 10. SUBJECT OF AMENDMENT: The proposed amendment updates the clinical diagnostic laboratory services page of the State Plan as a result of the 2020 Annual Healthcare Common Procedure Coding System updates for clinical diagnostic laboratory services. 11. GOVERNOR’S REVIEW (Check One): El GOVERNOR’S OFFICE REPORTED NO COMMENT OTHER, AS SPECIFIED: Sent to Governor’s Office this date. Comments, if any, will be forwarded upon receipt. El COMMENTS OF GOVERNOR’S OFFICE ENCLOSED El NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 12. SIGNATURE OF STATE AGENCY OFFICIAL: 16. RETURN TO: Stephanie Muth 13. TYPED NAME: State Medicaid Director . Post Office Box 13247, MC: H-100 Stephanie Muth Austin, Texas 78711 14. TITLE: State Medicaid Director 15. DATE SUBMITTED: March 31, 2020 FOR REGIONAL OFFICE USE ONLY 17. DATE RECEIVED: 18. DATE APPROVED: PLAN APPROVED - ONE COPY ATTACHED 19. EFFECTIVE DATE OF APPROVED MATERIAL: 20. SIGNATURE OF REGiONAL OFFICIAL: 21. TYPEDNAME: 22. TITLE: 23. REMARKS: FORM CMS — 179 (D7-92) 1/1/2020 Todd McMillion 6/17/2020 Director, Division of Reimbursement Review ** $24,948 $34,860 $35,042 -------- ---------- **State requested pen and ink change via email dated 06-09-2020
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State of Texas Attachment 4.19-B Page 1c TN: ____________ Approval Date: ____________ Supersedes TN: ____________ Effective Date: ____________ 3. Clinical Diagnostic Laboratory Services Medicaid providers of clinical diagnostic laboratory (CDL) services are reimbursed based on fee schedules as follows: (a) The Texas Department of State Health Services (DSHS) Laboratory provides Early and Periodic Screening, Diagnostic and Treatment (EPSDT) medical and newborn screening services through a federal freedom-of-choice exemption as well as any other laboratory services provided that are not covered by this exemption. The DSHS laboratory is reimbursed for all laboratory services provided at 108 percent of the Medicare fees. (b) Sole community hospitals are reimbursed the lesser of their billed charges or the fee determined by HHSC, which is 100 percent of the Medicare fee. Under Medicare, the fee schedule amount paid to sole community hospitals is three and one third percent higher than the fee schedule amount paid to other types of providers of CDL service. The Medicaid fee for any new procedure codes added during the year will be based on 96 percent of the Medicare fees in effect as of January 1 of that same year. (c) The remaining providers of these services are reimbursed the lesser of their billed charges or the fee determined by HHSC, which is 100 percent of the Medicare fee. The Medicaid fee for any new procedure codes added during the year will be based on 84 percent of the Medicare fees in effect as of January 1 of that same year. (d) The reimbursement methodologies in 3(a) – (c) ensure that Medicaid payments to these providers for these services meet the upper payment limit requirements in Section 1903(i)(7) of the Social Security Act by requiring that Medicaid payments for clinical laboratory services must not exceed the Medicare fee for the service on a per test basis. This provision does not apply to the DSHS laboratory reimbursement, which will be established at a percentage of the Medicare fee. (e) All fee schedules are available through the agency's website as outlined on Attachment 4.19-B, Page 1. (f) The agency's fee schedule was revised with new fees for clinical diagnostic laboratory services effective January 1, 2020, and was posted on the agency's website on March 15, 2020. 6/17/20 1/1/20 19-0022 20-0005
(spa)(tx-20-0020)(approval-document)Texas Medicaid SPA TX-20-0020: Approval Document (approved November 9, 2020, effective September 1, 2020)#
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Table of Contents State/Territory Name: Texas
State Plan Amendment (SPA) #: 20-0020 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages
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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Center for Medicaid & CHIP Services 233 North Michigan Ave., Suite 600 Chicago, Illinois 60601 Financial Management Group Ms. Stephanie Stephens State Medicaid/CHIP Director Health and Human Services Commission Mail Code: H100 Post Office Box 13247 Austin, Texas 78711 RE: Texas TN 20-0020 Dear Ms. Stephens: We have reviewed the proposed Texas State Plan Amendment (SPA) to Attachment 4.19-B, TX#20- 0020, which was submitted to the Centers for Medicare & Medicaid Services (CMS) on September 30, 2020. This state plan amendment updates the durable medical equipment, prosthetics, orthotics, supplies (DMEPOS) and vision care services fee schedules. Based upon the information provided by the State, we have approved the amendment with an effective date of September 1, 2020. We are enclosing the approved CMS-179 and a copy of the new state plan pages. If you have any additional questions or need further assistance, please contact Tamara Sampson at 214-767-6431 or Tamara.Sampson@cms.hhs.gov. Sincerely, Todd McMillion Director Division of Reimbursement Review Enclosures November 9, 2020
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED CENTERS FOR MEDICARE AND MEDICAID SERVICES OMB NO. 0938-0193 ROVAL OF STATE PLAN MATERIAL 20-0020 _—
FOR: CENTERS FOR MEDICARE AND MEDICAID SERVICES
3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID)
TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE AND MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES
4. PROPOSED EFFECTIVE DATE: September 1, 2020
5. TYPE OF PLAN MATERIAL (Circle One): O _sNEWSTATE PLAN
(1 AMENDMENT TO BE CONSIDERED AS NEW PLAN
@ AMENOMENT
COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment)
6. FEDERAL STATUTE/REGULATION CITATION:
Social Security Act §1902(a) (30); 42 CFR §447.201(b).
7. FEDERAL BUDGET IMPACT:
a. FFY 2020 $§ b. FFY 2021 $59 c. FFY 2022 $58
SEE ATTACHMENT
8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: Attachment 4.19 b Page 3a Page 3c
9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (/f Applicable): Attachment 4.19b Page 3a (TN 20-0016)
Page 3c (TN 18-0015)
10. SUBJECT OF AMENDMENT:
and vision care services fee schedules.
The proposed amendment updates the durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS)
11. GOVERNOR'S REVIEW (Check One): GOVERNOR'S OFFICE REPORTED NO COMMENT
NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL
& OTHER, AS SPECIFIED: Sent to Governor's Office this date. Comments, if any, will be forwarded upon receipt.
Oo (1 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED Oo 12,
15. OATE SUBMITTED: September 30, 2020
Stephanie Stephens 13. TYPED NAME: State Medicaid Director Stephanie Stephens Post Office Box 13247, MC: H-100 Austin, Texas 78711 14. TITLE: State Medicaid Director
FOR REGIONAL OFFICE USE ONLY
17. DATE RECEIVED: 9/30/2020
18. DATE APPROVED: 11/9/2020
| PLAN APPROVED — ONE COPY ATTACHED
19. EFFECTIVE DATE OF APPROVED MATERIAL:
20. SIGNATURE OF REGIONAL OFFICIAL:
9/1/2020 21. TYPED NAME: 22. TITLE: Todd McMillion Director, Division of Reimbursement Review 23. REMARKS:
FORM CMS — 179 (07-92)
(spa)(tx-20-0020)(approval-document)(page-4)Page 4#
State of Texas Attachment 4.19-B Page 3a TN: ___20-0020 Approval Date: ____________ Supersedes TN: 20-0016___ Effective Date: __9/1/20
8. Home Health Services (continued) (b) Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) (1) If the item of DMEPOS is covered by Medicare, the Medicaid fee will be equal to or a percentage of the Medicare fee schedule specific to Texas that is available at the time of the fee review, unless there is documentation that the Medicare fee is insufficient for the items covered under the procedure code and required by the Medicaid population. (2) For items of DMEPOS not paid at the Medicare fee, the provider will either be reimbursed a fee determined by HHSC or through manual pricing. The fee determined by HHSC will be determined from cost information from providers, manufacturers, surveys of the Medicaid fees for other states, survey information from national fee analyzers, or other relevant fee-related information. (3) Manual pricing is reasonable when one procedure code covers a broad range of items with a broad range of costs, since a single fee may not be a reasonable fee for all items covered under the procedure code, resulting in access-to-care issues. Examples include 1) procedure codes with a description of “not otherwise covered,” “unclassified,” or “other miscellaneous;” and 2) procedure codes covering customized items. If manual pricing is used, the provider is reimbursed either the documented Manufacturer's Suggested Retail Price (MSRP) less 18 percent, or the documented Average Wholesale Price (AWP) less 10.5 percent, whichever one is applicable. If one of these is not available, the provider's documented invoice cost is used as the basis for manual pricing. AWP pricing is used primarily for nutritional products and DMEPOS items sold in pharmacies. (4) The Medicaid fees for oxygen equipment, oxygen, and oxygen-related supplies will not exceed the Medicare fee for the same procedure code. (5) All fee schedules are available through the agency’s website as outlined on Attachment 4.19-B, page 1. (6) The agency’s fee schedule was revised with new fees for durable medical equipment, prosthetics, orthotics, and supplies effective September 1, 2020 and was posted on the agency’s website on September 15, 2020. 11/9/20
(spa)(tx-20-0020)(approval-document)(page-5)Page 5#
State of Texas Attachment 4.19-B Page 3c TN: _____20-0020___ Approval Date: ____________ Supersedes TN: _____18-0015___ Effective Date: ____9/1/20___ 10. Vision Care Services (a) Providers of professional vision services are reimbursed based on the lesser of the provider's billed charges or fees determined by HHSC in accordance with Item 1 of this attachment, relating to the reimbursement methodology for physicians and certain other practitioners. (b) Providers of eyeglasses and contact lenses are reimbursed the lesser of the provider's billed charges or fees determined by HHSC, which are based on a review of Medicare fees and/or other data available to HHSC, such a relevant cost or fee surveys. (c) All fee schedules are available through the agency’s website, as outlined on Attachment 4.19-B, page 1. (d) The agency’s fee schedule was revised with new fees for vision care services effective September 1, 2020, and this fee schedule was posted on the agency’s website on September 15, 2020. 11/9/20
(spa)(tx-21-0021)(approval-document)Texas Medicaid SPA TX-21-0021: Approval Document (approved June 2, 2021, effective January 1, 2021)#
(spa)(tx-21-0021)(approval-document)(page-1)Page 1#
Table of Contents State/Territory Name: Texas State Plan Amendment (SPA) #: 21-0021 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages
(spa)(tx-21-0021)(approval-document)(page-2)Page 2#
DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Center for Medicaid & CHIP Services 233 North Michigan Ave., Suite 600 Chicago, Illinois 60601 Financial Management Group Ms. Stephanie Stephens State Medicaid/CHIP Director Health and Human Services Commission Mail Code: H100 Post Office Box 13247 Austin, Texas 78711 RE: Texas TN 21-0021 Dear Ms. Stephens: We have reviewed the proposed Texas State Plan Amendment (SPA) to Attachment 4.19-B, TX#21- 0021, which was submitted to the Centers for Medicare & Medicaid Services (CMS) on March 31, 2021. This state plan amendment updates the fee schedule for clinical diagnostic laboratory services. Based upon the information provided by the State, we have approved the amendment with an effective date of January 1, 2021. We are enclosing the approved CMS-179 and a copy of the new state plan page. If you have any additional questions or need further assistance, please contact Tamara Sampson at 214-767-6431 or Tamara.Sampson@cms.hhs.gov. Sincerely, Todd McMillion Director Division of Reimbursement Review Enclosures June 2, 2021
(spa)(tx-21-0021)(approval-document)(page-3)Page 3#
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE AND MEDICAID SERVICES OMB NO. 0938-0193 1. TRANSMITTAL NUMBER: 2. STATE: TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL 21-0021 TEXAS
FOR: CENTERS FOR MEDICARE AND MEDICAID SERVICES
3. PROGRAM IDENTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID)
TO: REGIONAL ADMINISTRATOR CENTERS FOR MEDICARE AND MEDICAID SERVICES DEPARTMENT OF HEALTH AND HUMAN SERVICES
4. PROPOSED EFFECTIVE DATE: January 1, 2021
5. TYPE OF PLAN MATERIAL (Circle One): Oo NEW STATE PLAN
[J AMENDMENT TO BE CONSIDERED AS NEW PLAN
KI AMENDMENT
COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT (Separate Transmittal for each amendment)
6. FEDERAL STATUTE/REGULATION CITATION:
Social Security Act §1902(a)(30); 42 CFR §447.201(b)
7. FEDERAL BUDGET IMPACT: SEE ATTACHMENT a. FFY 2021 ($0.31) b. FFY 2022 ($0.36) c. FFY 2023 ($0.34)
8. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT:
Attachment 4.19-B Page 1c
9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR ATTACHMENT (/f Applicable):
Attachment 4.19-B Page 1c (TN 20-0005)
10. SUBJECT OF AMENDMENT:
The proposed amendment updates the clinical diagnostic laboratory services of the state plan.
11. GOVERNOR'S REVIEW (Check One): GOVERNOR'S OFFICE REPORTED NO COMMENT
COMMENTS OF GOVERNOR'S OFFICE ENCLOSED NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL
[X] OTHER, AS SPECIFIED: Sent to Governor's Office this date. Comments, if any, will be forwarded upon receipt.
oO Oo Oo 12
13. TYPED NAME: Stephanie Stephens
14. TITLE:
State Medicaid Director
15. DATE SUBMITTED:
March 31, 2021
16. RETURN TO:
Stephanie Stephens
State Medicaid Director
Post Office Box 13247, MC: H-100 Austin, Texas 78711
FOR REGIONAL OFFICE USE ONLY
17. DATE RECEIVED: March 31, 2021
18. DATE APPROVED: June 2, 2021
PLAN APPROVED — ONE COPY ATTACHED
19. EFFECTIVE DATE OF APPROVED MATERIAL:
20. SIGNATURE OF REGIONAL OFFICIAL:
21. TYPED NAME: 22. TITLE: Todd McMillion Director, Division of Reimbursement Review 23. REMARKS:
FORM CMS — 179 (07-92)
(spa)(tx-21-0021)(approval-document)(page-4)Page 4#
State of Texas Attachment 4.19-B Page 1c 3. Clinical Diagnostic Laboratory Services Medicaid providers of clinical diagnostic laboratory (CDL) services are reimbursed based on fee schedules as follows: (a) The Texas Department of State Health Services (DSHS) Laboratory provides Early and Periodic Screening, Diagnostic and Treatment (EPSDT) medical and newborn screening services through a federal freedom-of-choice exemption as well as any other laboratory services provided that are not covered by this exemption. The DSHS laboratory is reimbursed for all laboratory services provided at a percentage of the Medicare fees. (b) Sole community hospitals are reimbursed the lesser of their billed charges or the fee determined by HHSC, which is a percentage of the Medicare fee. Under Medicare, the fee schedule amount paid to sole community hospitals is three and one third percent higher than the fee schedule amount paid to other types of providers of CDL service. The Medicaid fee for any new procedure codes added during the year will be based on a percentage of the Medicare fees in effect as of January 1 of that same year. (c) The remaining providers of these services are reimbursed the lesser of their billed charges or the fee determined by HHSC, which is a percentage of the Medicare fee. The Medicaid fee for any new procedure codes added during the year will be based on a percentage of the Medicare fees in effect as of January 1 of that same year. (d) The reimbursement methodologies in 3(a) – (c) ensure that Medicaid payments to these providers for these services meet the upper payment limit requirements in Section 1903(i)(7) of the Social Security Act by requiring that Medicaid payments for clinical laboratory services must not exceed the Medicare fee for the service on a per test basis. This provision does not apply to the DSHS laboratory reimbursement, Rural Hospitals, or Sole Community Hospitals, which will be established at a percentage of the Medicare fee. (e) All fee schedules are available through the agency's website as outlined on Attachment 4.19-B, Page 1. (f) For services related to testing of Covid-19 (coronavirus), CDL services provided outside of the DSHS Laboratory are reimbursed at 100% of the Medicare rate. (g) The agency's fee schedule was revised with new fees for clinical diagnostic laboratory services effective January 1, 2021, and was posted on the agency's website on March 19, 2021. TN: 21-0021 Approval Date: Superseded TN:20-0005 Effective Date: 01/01/2021 06/02/2021
(spa)(tx-21-0048)(approval-document)Texas Medicaid SPA TX-21-0048: Approval Document (approved December 14, 2021, effective September 1, 2021)#
(spa)(tx-21-0048)(approval-document)(block-1)Texas Medicaid SPA TX-21-0048: Approval Document (approved December 14, 2021, effective September 1, 2021)#
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(spa)(tx-23-0015)(approval-document)Texas Medicaid SPA TX-23-0015: Approval Document (approved January 25, 2024, effective January 1, 2023)#
(spa)(tx-23-0015)(approval-document)(page-1)Page 1#
Table of Contents State/Territory Name: Texas State Plan Amendment (SPA) #: 23-0015 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages
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Records / Submission Packages - View All TX - Submission Package - TX2023MS0001O - (TX-23-0015) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter RAI Transaction Logs News Related Actions DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Medicaid and CHIP Operations Group 601 E. 12th Street Room 355 Kansas City, KS 64106 Center for Medicaid & CHIP Services January 25, 2024 Emily Zalkovsky State Medical DIrector Texas Health and Human Services Commission Post Office Box 13247 Mail Code: H100 Austin, TX 78711 Re: Approval of State Plan Amendment TX-23-0015 Dear Emily Zalkovsky, On March 31, 2023, the Centers for Medicare and Medicaid Services (CMS) received Texas State Plan Amendment (SPA) TX-23-0015, in which the state proposed to adopt the changes to the eligibility rules for the Former Foster Care Children eligibility group, as enacted by the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act, Pub. L. No. 115-217, section 1002. We approve Texas State Plan Amendment (SPA) TX-23-0015 with an effective date(s) of January 01, 2023. If you have any questions, please contact Tobias Griffin via email at tobias.griffin@cms.hhs.gov. Sincerely, Ruth A. Hughes Acting Director, Division of Program Operations Center for Medicaid & CHIP Services
(spa)(tx-23-0015)(approval-document)(page-3)Page 3#
Records / Submission Packages - View All TX - Submission Package - TX2023MS0001O - (TX-23-0015) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter RAI Transaction Logs News Related Actions CMS-10434 OMB 0938-1188 Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | TX2023MS0001O | TX-23-0015 Package Header Package ID TX2023MS0001O Submission Type Official Approval Date 01/25/2024 Superseded SPA ID N/A SPA ID TX-23-0015 Initial Submission Date 3/31/2023 Effective Date N/A State Information State/Territory Name: Texas Medicaid Agency Name: Texas Health and Human Services Commission Submission Component State Plan Amendment Medicaid CHIP 0 0 0
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Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | TX2023MS0001O | TX-23-0015 Package Header Package ID TX2023MS0001O Submission Type Official Approval Date 01/25/2024 Superseded SPA ID N/A SPA ID TX-23-0015 Initial Submission Date 3/31/2023 Effective Date N/A SPA ID and Effective Date SPA ID TX-23-0015 Reviewable Unit Proposed Effective Date Superseded SPA ID Mandatory Eligibility Groups 1/1/2023 TX-17-0024 Former Foster Care Children 1/1/2023 TX-14-02 MM1 Page Number of the Superseded Plan Section or Attachment (If Applicable):
(spa)(tx-23-0015)(approval-document)(page-5)Page 5#
Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | TX2023MS0001O | TX-23-0015 Package Header Package ID TX2023MS0001O Submission Type Official Approval Date 01/25/2024 Superseded SPA ID N/A SPA ID TX-23-0015 Initial Submission Date 3/31/2023 Effective Date N/A Executive Summary Summary Description Including Goals and Objectives The purpose of this amendment is to provide Medicaid eligibility to individuals who aged out of the foster care system in a state otherthan Texas on or after January 1, 2023 and who were receiving Medicaid in that state when they aged out of foster care. Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First 2023 $0 Second 2024 $0 Federal Statute / Regulation Citation Section 1002(a) SUPPORT Act, Pub. L. No. 115-271 Supporting documentation of budget impact is uploaded (optional). Name Date Created No items available
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Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | TX2023MS0001O | TX-23-0015 Package Header Package ID TX2023MS0001O Submission Type Official Approval Date 01/25/2024 Superseded SPA ID N/A SPA ID TX-23-0015 Initial Submission Date 3/31/2023 Effective Date N/A Governor's Office Review Describe Sent to Governor's office this date. Comments, if any, will be forwarded upon receipt. No comment Comments received No response within 45 days Other 0 0 0 0
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PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 1/26/2024 5:21 PM EST
(spa)(tx-23-0015)(approval-document)(page-8)Page 8#
Records / Submission Packages - View All TX - Submission Package - TX2023MS0001O - (TX-23-0015) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter RAI Transaction Logs News Related Actions CMS-10434 OMB 0938-1188 Medicaid State Plan Eligibility Mandatory Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | TX2023MS0001O | TX-23-0015 Package Header Package ID TX2023MS0001O Submission Type Official Approval Date 01/25/2024 Superseded SPA ID TX-17-0024 System-Derived SPA ID TX-23-0015 Initial Submission Date 3/31/2023 Effective Date 1/1/2023 Mandatory Coverage A. The state provides Medicaid to mandatory groups of individuals. The mandatory groups covered are: Families and Adults Eligibility Group Name Covered In State Plan Include RU In Package Included in Another Submission Package Source Type Infants and Children under Age 19 CONVERTED Parents and Other Caretaker Relatives APPROVED Pregnant Women CONVERTED Deemed Newborns NEW Children with Title IV-E Adoption Assistance, Foster Care or Guardianship Care NEW Former Foster Care Children APPROVED Transitional Medical Assistance NEW Extended Medicaid due to Spousal Support Collections NEW Aged, Blind and Disabled Eligibility Group Name Covered In State Plan Include RU In Package Included in Another Submission Package Source Type SSI Beneficiaries NEW Closed Eligibility Groups NEW Individuals Deemed To Be Receiving SSI NEW
[!] C: [!] C: [!] C: [!] C: [!] [!] C: [!] C: [!] C: C: C: □ □ □ □ □ C: □ □ □ □ □ 0 0 0 0 0 0 0 0 0 0 0
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Eligibility Group Name Covered In State Plan Include RU In Package Included in Another Submission Package Source Type Working Individuals under 1619(b) NEW Qualified Medicare Beneficiaries NEW Qualified Disabled and Working Individuals NEW Specified Low Income Medicare Beneficiaries NEW Qualifying Individuals NEW
C C C C C □ □ □ □ □ 0 0 0 0 0
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Mandatory Eligibility Groups MEDICAID | Medicaid State Plan | Eligibility | TX2023MS0001O | TX-23-0015 Package Header Package ID TX2023MS0001O Submission Type Official Approval Date 01/25/2024 Superseded SPA ID TX-17-0024 System-Derived SPA ID TX-23-0015 Initial Submission Date 3/31/2023 Effective Date 1/1/2023 B. The state elects the Adult Group, described at 42 CFR 435.119. C. Additional Information (optional) Eligibility Groups Deselected from Coverage The following eligibility groups were previously covered in the source approved version of the state plan and deselected from coverage as part of this submission package: N/A Yes No 0 0
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Medicaid State Plan Eligibility Eligibility Groups - Mandatory Coverage Former Foster Care Children MEDICAID | Medicaid State Plan | Eligibility | TX2023MS0001O | TX-23-0015 Individuals under the age of 26, who were in foster care and on Medicaid when they turned age 18 or aged out of foster care. Package Header Package ID TX2023MS0001O Submission Type Official Approval Date 01/25/2024 Superseded SPA ID TX-14-02 MM1 User-Entered SPA ID TX-23-0015 Initial Submission Date 3/31/2023 Effective Date 1/1/2023 The state covers the mandatory former foster care children group in accordance with the following provisions: A. Characteristics Individuals qualifying under this eligibility group must meet the following criteria: 1. Are under age 26 2. Were in foster care upon attaining age 18 or a higher age at which the state's or Tribe's foster care assistance ends under title IV-E of the Act (up to age 21). 3. Are described under either Section B. or C. B. Individuals Covered For individuals who turn 18 before January 1, 2023: 1. The state covers individuals who: a. Upon attaining age 18 or a higher age at which the state's or Tribe's foster care assistance ends under title IV-E of the Act (up to age 21) were: i. In foster care under the responsibility of the state or a Tribe within the state (including children who were cared for through a grant to the state under the unaccompanied refugee minor program); and ii. Enrolled in Medicaid under the state's Medicaid state plan or 1115 demonstration; and b. Are not otherwise eligible for and enrolled for mandatory coverage under the state plan, except that eligibility under this group takes precedence over eligibility under the Adult Group. 2. In addition to B.1., the state elects to cover individuals who were in foster care under the responsibility of the state or a Tribe within the state (including children who were cared for through a grant to the state under the unaccompanied refugee minor program) when they turned 18 or a higher age at which the state's or Tribe's foster care assistance ends under title IV-E of the Act, and meet the following criteria: C. Individuals Covered For individuals who turn 18 on or after January 1, 2023: 1. The state covers individuals who: a. Upon attaining age 18 or a higher age at which the state's or Tribe's foster care assistance ends under title IV-E of the Act (up to age 21) were: i. In foster care under the responsibility of any state or a Tribe within any state (including children who were cared for through a grant to the state under the unaccompanied refugee minor program); and ii. Enrolled in Medicaid under a state's Medicaid state plan or 1115 demonstration; and b. Are not enrolled in mandatory coverage under the state plan, except that eligibility under this group takes precedence over eligibility under the Adult Group. 2. In addition to C.1., the state elects to cover individuals who were in foster care under the responsibility of any state or a Tribe within any state (including children who were cared for through a grant to a state under the unaccompanied refugee minor program) when they turned 18 or a higher age at which that state's or Tribe's foster care assistance ends under title IV-E of the Act, and meet the following criteria: a. They were enrolled in Medicaid under the state's Medicaid state plan or 1115 demonstration at any time during the foster care period in which they turned 18 or a higher age at which the state's or Tribe's foster care assistance ends. b. They were placed by the state or Tribe in another state and were enrolled in Medicaid under the other state’s Medicaid state plan or 1115 demonstration project when they turned 18 or a higher age at which the state's or Tribe's foster care assistance ends. c. They were placed by the state or Tribe in another state and were enrolled in Medicaid under the other state’s Medicaid state plan or 1115 demonstration project at any time during the foster care period in which they turned 18 or a higher age at which the state's or Tribe's foster care assistance ends. a. They were enrolled in Medicaid under a state's Medicaid state plan or 1115 demonstration at any time during the foster care period in which they turned 18 or a higher age at which a state's or Tribe's foster care assistance ends. b. They were placed by a state or Tribe in another state and were enrolled in Medicaid under the other state’s Medicaid state plan or 1115 demonstration project when they turned 18 or a higher age at which a state's or Tribe's foster care assistance ends. c. They were placed by a state or Tribe in another state and were enrolled in Medicaid under the other state’s Medicaid state plan or 1115 demonstration project at any time during the foster care period in which they turned 18 or a higher age at which a state's or Tribe's foster care assistance ends. □ □ □ □ □ □
(spa)(tx-23-0015)(approval-document)(page-12)Page 12#
Former Foster Care Children MEDICAID | Medicaid State Plan | Eligibility | TX2023MS0001O | TX-23-0015 Package Header Package ID TX2023MS0001O Submission Type Official Approval Date 01/25/2024 Superseded SPA ID TX-14-02 MM1 User-Entered SPA ID TX-23-0015 Initial Submission Date 3/31/2023 Effective Date 1/1/2023 D. Additional Information (optional)
(spa)(tx-23-0015)(approval-document)(page-13)Page 13#
PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 1/26/2024 5:23 PM EST
(spa)(tx-23-0027)(approval-document)Texas Medicaid SPA TX-23-0027: Approval Document (approved February 13, 2024, effective January 1, 2024)#
(spa)(tx-23-0027)(approval-document)(page-1)Page 1#
Table of Contents State/Territory Name: Texas State Plan Amendment (SPA) #: 23-0027 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages
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DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Seivices 601 E. 12th St., Room 355 Kansas City Missouri 64106 Medicaid and CHIP Operations Group Febma1y 13 2024 Emily Zalkovsky State Medicaid Director Texas Health and Human Services Commission Mail Code: HlO0 P.O. Box 13247 Austin TX 78711 -3247 Re: Texas State Plan Amendment (SPA) TX-23-0027 Dear Director Zalkovsky: CENTERS FOR MEDICARE & MEDICAID SERVICES CENTER FOR MEDICA.ID & CHIP SERVICES The Centers for Medicare & Medicaid Se1vices (CMS) reviewed your Medicaid State Plan Amendment (SPA) submitted under transmittal number (1N) 23-0027. This amendment proposes to update the state's minimum personal needs allowance for individuals residing in a nursing facility (NF) assisted living facility, inte1mediate care facilities for individuals with intellectual disabilities (ICFs/IID), or other similar long-te1m care facility from $60 to $75 for individuals and from $120 to $150 for couples. We conducted our review of your submittal according to statut01y requirements in Title XIX of the Social Security Act and implementing regulations 42 U.S.C §1396a(q); 42 CFR §435.725; 42 CFR §435.726, Human Resources Code §32.024(w). This letter is to inform you that Texas Medicaid SPA 23-0027 was approved on Febrnaiy 13, 2024, with an effective date of Januaiy 1, 2024. If you have any questions, please contact Tobias Gtiffin at 214-767-4425 or via email at Tobias.Griffin@cms.hhs.gov. Digitally signed by Ruth Hughes-5 Date: 2024.02.13 11 :47:03 -{)6'00' Ruth A. Hughes, Acting Director Division of Program Operations cc: Kathi Montalbano, Texas State Plan and Waiver Manager Ford Blunt, MCOG West Branch Acting Manager
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DEPARTMENT OF HEAL TH ANDHUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES TRANSMITTAL AND NOTICE OF APPROVAL OF STATE PLAN MATERIAL FOR: CENTERS FOR MEDICARE & MEDICAID SERVICES TO: CENTER DIRECTOR CENTERS FOR MEDICAID & CHIP SERVICES DEPARTMENT OF HEAL TH AND HUMAN SERVICES 5. FEDERAL STATUTE/REGULATION CITATION 1. TRAN SM ITT AL NUMBER 2 3 _ o 0 2 2. STATE 7 T FORM APPROVED 0MB No. 0938-0193 X ---- - ------ -- 3. PROGRAM IDENTIFICATION: TITLE OF THE SOCIAL SECURITY ACT • XIX 4. PROPOSED EFFECTIVE DATE January 01, 2024 6. FEDERAL BUDGET IMPACT (Amounts in WHOLE dollars) a. FFY 2024 $ 688 923 42 U.S.C §1396a(q); 42 CFR §435.725; 42 CFR §435.726, b. FFY 2025 $ 949 212 Human Resources Code §32.024(w). 7. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT 8. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION Attachment 2.6-A, OR ATTACHMENT (If Applicable) Page 4a Attachment 2.6-A, Supplement 12 to Attachment 2.6-A, Page 4a (TN 09-32) Page 1 Supplement 12 to Attachment 2.6-A, Page 1 (TN 09-32) 9. SUBJECT OF AMENDMENT The purpose of this amendment is to update the state's minimum personal needs allowance for individuals residing in a nursing facility (NF), assisted living facility, intermediate care facilities for individuals with intellectual disabilities (ICFs/llD), or other similar long-term care facility from $60 to $75 for individuals and from $120 to $150 for couples. The proposed amendment is due to a change in law, House Bill 54, 88th Legislature, Regular Session 2023. 10. GOVERNOR'S REVIEW (Check One) □ GOVERNOR'S OFFICE REPORTED NO COMMENT □ COMMENTS OF GOVERNOR'S OFFICE ENCLOSED □No REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL 11 . SIGNATURE OF STATE AGENCY OFFICIAL Em i I y Za I k o vs ky i:Pa~1a~~2\ig1"!1J>~J=mi\~f-&98&ky "IL. I Yr-cu 1'111"\IVIC Emily Zalkovsky 13. TITLE State Medicaid Director 14. DATE SUBMITTED December 15, 2023 El OTHER, AS SPECIFIED: Sent to Governor's Office this date. Comments, if any, will be forwarded upon receipt. 15. RETURN TO Emily Zalkovsky State Medicaid Director Post Office Box 13247, MC: H-100 Austin, Texas 78711 FOR CMS USE ONLY 16. DATE RECEIVED December 15, 2023 17. DATE APPROVED February 13, 2024 PLAN APPROVED - ONE COPY ATTACHED 18. EFFECTIVE DATE OF APPROVED MATERIAL January 1, 2024. 20. TYPED NAME OF APPROVING OFFICIAL Ruth A. Hughes 22. REMARKS FORM CMS-179 (09124) 19. SIGNATUR 21. TITLE OF APPROVING OFFICIAL Digitally signed by Ruth Hughes -5 Date: 2024.02.13 11 :48:44 -06'00' Acting Director, Division of Program Operations
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Approval Date: )HEUXDU\ TN: 23-0027 Supersedes TN: 09-32 Effective Date: January 1, 2024 State of Texas Attachment 2.6-A Page 4a OMB No.:0938-0673 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM State: Texas Citation Condition or Requirement 1924 of the Act 435.725 435.733 435.832 B. Post eligibility Treatment of Institutionalized Individuals' Incomes, Cont. 2. The following monthly amounts for personal needs are deducted from total monthly income in the application of an institutionalized individual's or couple's income to the cost of institutionalized care: Personal Needs Allowance (PNA) of not less than $30 for Individuals and $60 for Couples for all Institutionalized Persons. a. Aged Blind, Disabled: Individuals:$75.00 Couples: $150.00 For the following persons with greater needs: Supplement 12 to Attachment 2.6-A describes the greater need of an institutionalized individual with a court ordered guardianship/fiduciary fee when calculating the cost of institutionalized care. b. AFDC related: Children: $ 45.00 Adults: $ 45.00 For the following persons with greater need: Supplement 12 to Attachment 2.6-A described the greater need; described the basis or formula for determining the deductible amount when a specific amount is not listed above; lists the criteria to be met; c. Individuals under age 21 covered in the plan as specified in Item B.7 of Attachment 2.2-A.
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Approval Date: )HEUXDU\ TN: 23-0027 Supersedes TN: 09-32 Effective Date: January 1, 2024 State of Texas Supplement 12 to Attachment 2.6-A Page 1 0MB No.:0938-0673 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM State: TEXAS VARIATIONS FROM THE BASIC PERSONAL NEEDS ALLOWANCE As earnings increase the following individuals have greater need due to work related expenses: The method used to calculate the amount of Personal Needs Allowance that can be retained by persons living in ICF/MR facilities with earnings is as follows: • If an individual earns $30 or less: In addition to the basic Personal Needs Allowance, individuals with earnings up to $30 keep an additional amount up to the $30 earned. • If an individual's net monthly earnings exceed $30 but do not exceed $120: In addition to the basic Personal Needs Allowance, individuals with earnings above $30 but less than $120 keep an additional amount which includes the first $30 earned, plus one half of whatever amount exceeds that up to $120. • If an individual's net monthly earnings exceed $120: In addition to the basic Personal Needs Allowance, individuals with earnings above $120 keep an additional amount which includes the first $30 earned, plus one half of whatever amount exceeds that up to $120, plus 30% of the amount greater than $120. All institutionalized individuals may receive a deduction from the cost of care in an institution for court ordered guardianship/fiduciary fees. The deduction is limited to guardianship-related costs and fees, subject to the limitations of the Texas Probate Code.
(spa)(tx-23-0028)(approval-document)Texas Medicaid SPA TX-23-0028: Approval Document (approved January 17, 2024, effective March 1, 2024)#
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Table of Contents State/Territory Name: TX State Plan Amendment (SPA) #: 23-0028 This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like data) 3) Approved SPA Pages
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(spa)(tx-24-0001)(approval-document)Texas Medicaid SPA TX-24-0001: Approval Document (approved May 15, 2024, effective January 1, 2024)#
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Table of Contents State/Territory Name: Texas State Plan Amendment (SPA) #: 24-0001 This file contains the following documents in the order listed: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages
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Records / Submission Packages - View All TX - Submission Package - TX2024MS0001O - (TX-24-0001) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Medicaid and CHIP Operations Group 601 E. 12th St. Room 355 Kansas City, MO 64106 Center for Medicaid & CHIP Services May 15, 2024 Emily Zalkovsky State Medicaid Director Texas Health and Human Services Commission (HHSC) P.O. Box 13247 Austin, TX 78711-3247 Re: Approval of State Plan Amendment TX-24-0001 Dear Emily Zalkovsky, On March 28, 2024, the Centers for Medicare and Medicaid Services (CMS) received Texas State Plan Amendment (SPA) TX-24-0001 to provide children under age 19 with 12 months of continuous eligibility in Medicaid, in accordance with Section 1902(e)(12) of the Social Security Act, as amended by Section 5112 of the Consolidated Appropriations Act, 2023. Children under age 19 will remain continuously eligible for the full 12-month certification period, regardless of changes in circumstances with certain exceptions. We approve Texas State Plan Amendment (SPA) TX-24-0001 with an effective date(s) of January 01, 2024. If you have any questions regarding this amendment, please contact Ford Blunt at ford.blunt@cms.hhs.gov Sincerely, James G. Scott Director - Division of Program Operations Center for Medicaid & CHIP Services MS CIN'TElS FOR MEDICARE & MEDICAID UIV1C£S
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Records / Submission Packages - View All TX - Submission Package - TX2024MS0001O - (TX-24-0001) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions CMS-10434 OMB 0938-1188 Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | TX2024MS0001O | TX-24-0001 Package Header Package ID TX2024MS0001O Submission Type Official Approval Date 05/15/2024 Superseded SPA ID N/A SPA ID TX-24-0001 Initial Submission Date 3/28/2024 Effective Date N/A State Information State/Territory Name: Texas Medicaid Agency Name: Texas Health and Human Services Commission Submission Component State Plan Amendment Medicaid CHIP 0 0 0
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Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | TX2024MS0001O | TX-24-0001 Package Header Package ID TX2024MS0001O Submission Type Official Approval Date 05/15/2024 Superseded SPA ID N/A SPA ID TX-24-0001 Initial Submission Date 3/28/2024 Effective Date N/A SPA ID and Effective Date SPA ID TX-24-0001 Reviewable Unit Proposed Effective Date Superseded SPA ID Continuous Eligibility for Children 1/1/2024 New Page Number of the Superseded Plan Section or Attachment (If Applicable):
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Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | TX2024MS0001O | TX-24-0001 Package Header Package ID TX2024MS0001O Submission Type Official Approval Date 05/15/2024 Superseded SPA ID N/A SPA ID TX-24-0001 Initial Submission Date 3/28/2024 Effective Date N/A Executive Summary Summary Description Including Goals and Objectives The purpose of this amendment is to provide children under age 19 with 12 months of continuous eligibility in Medicaid, in accordance with Section 1902(e)(12) of the Social Security Act, as amended by Section 5112 of the Consolidated Appropriations Act, 2023. Children under age 19 will remain continuously eligible for the full 12-month certification period, regardless of changes in circumstances with certain exceptions. Federal Budget Impact and Statute/Regulation Citation Federal Budget Impact Federal Fiscal Year Amount First 2024 $7410000 Second 2025 $13340000 Federal Statute / Regulation Citation Section 1902(e)(12) of the Social Security Act Supporting documentation of budget impact is uploaded (optional). Name Date Created No items available
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Submission - Summary MEDICAID | Medicaid State Plan | Eligibility | TX2024MS0001O | TX-24-0001 Package Header Package ID TX2024MS0001O Submission Type Official Approval Date 05/15/2024 Superseded SPA ID N/A SPA ID TX-24-0001 Initial Submission Date 3/28/2024 Effective Date N/A Governor's Office Review No comment Comments received No response within 45 days Other 0 0 0 0
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PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 5/17/2024 12:40 PM EDT
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Records / Submission Packages - View All TX - Submission Package - TX2024MS0001O - (TX-24-0001) - Eligibility Summary Reviewable Units Versions Correspondence Log Analyst Notes Approval Letter Transaction Logs News Related Actions CMS-10434 OMB 0938-1188 Medicaid State Plan Eligibility Eligibility and Enrollment Processes Continuous Eligibility for Children MEDICAID | Medicaid State Plan | Eligibility | TX2024MS0001O | TX-24-0001 Package Header Package ID TX2024MS0001O Submission Type Official Approval Date 05/15/2024 Superseded SPA ID New User-Entered SPA ID TX-24-0001 Initial Submission Date 3/28/2024 Effective Date 1/1/2024 The state provides continuous eligibility for children in accordance with the following provisions: A. Mandatory Continuous Eligibility for Hospitalized Children The state provides Medicaid to a child eligible for and enrolled under the Infants and Children under Age 19 (42 CFR 435.118) eligibility group until the end of an inpatient stay for which inpatient services are covered, if the child: 1. Was receiving inpatient services covered by Medicaid on the date the child becomes ineligible under the eligibility group based on the child's age; and 2. Would remain eligible but for attaining such age. B. Mandatory Continuous Eligibility for Children The state provides continuous eligibility to all children under age 19 and that: 1. The continuous eligibility period begins on the effective date of the child's most recent determination or redetermination of eligibility, and ends the last day of the earlier of the following periods: a. The month that the child turns 19 years old; b. 12 months. 2. Continuous eligibility is provided to children eligible under all mandatory and optional eligibility groups (excluding Medically Needy) who would otherwise lose eligibility because of any change in circumstances, unless: a. The child dies; b. The child or the child's representative voluntarily requests a termination of the child's eligibility; c. The child ceases to be a resident of the state; d. The Medicaid agency determines that eligibility was determined incorrectly at the most recent determination or redetermination of eligibility because of agency error or fraud, abuse, or perjury attributed to the child or the child's representative; or e. The child attains the maximum age specified in B. C. Additional Information (optional) PRA Disclosure Statement: Centers for Medicare & Medicaid Services (CMS) collects this mandatory information in accordance with (42 U.S.C. 1396a) and (42 CFR 430.12); which sets forth the authority for the submittal and collection of state plans and plan amendment information in a format defined by CMS for the purpose of improving the state application and federal review processes, improve federal program management of Medicaid programs and Children’s Health Insurance Program, and to standardize Medicaid program data which covers basic requirements, and individualized content that reflects the characteristics of the particular state’s program. The information will be used to monitor and analyze performance metrics related to the Medicaid and Children’s Health Insurance Program in efforts to boost program integrity efforts, improve performance and accountability across the programs. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1188. The time required to complete this information collection is estimated to range from 1 hour to 80 hours per response (see below), including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. This view was generated on 5/17/2024 12:41 PM EDT
(spa-index)(p01)Texas Medicaid state plan amendments on medicaid.gov: SPA index page 1 of 7#
(spa-index)(p01)(block-1)Medicaid State Plan Amendments#
This plan amendment has an effective date of February 1, 2021, and is intended to amend the description of the reimbursement methodology for both the Alternative Payment Methodology (APM) and Prospective Payment System (PPS) methodologies for Federally Qualified Health Centers (FQHC).
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The purpose of this SPA is to make changes to the Medicaid Estate Recovery Program (MERP). These changes clarify MERP eligibility requirements to ensure proper recovery of Medicaid long-term care costs.
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This plan amendment implements the Patient Driven Payment Model for Long Term Care (PDPM LTC) rate methodology and payment rates for Nursing Facilities (NFs).
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The proposed amendment updates the Physicians' and Other Licensed Practitioners’ Services fee schedule.
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This plan amendment updates the Clinical Diagnostic Laboratory Services fee schedules (CDL).
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This plan amendment updates Durable Medical Equipment, Prosthetics, Orthotics, and Supplies Services fee schedules.
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This plan amendment updates updates reimbursement methodologies for hospitals inpatient services to include an obstetrics-gynecology (OBGYN) add-on to eligible rural hospitals standard dollar amount (SDA) rates and makes other non-substantive clarifications.
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This plan amendment increase the wage for personal attendants under Medicaid to an average of $13.00 per hour and discontinues the attendant compensation rate enhancement program.
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This plan amendment establishes a rate methodology to equal the skilled NF Medicare rate without therapy components, adjusted using the highest case-mix index and increases the wage for personal attendants to an average of $13.00 per hour.
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The proposed amendment updates the Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program fee schedules.
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The changes are based on the current and approved methodology for the covered services to increase the wage for personal attendants to $13.00 per hour and Rider 23 also discontinues the attendant compensation rate enhancement program.
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This plan amendment updates the Primary Home Care (PHC) attendant wage to increase the wage for personal attendants to $13.00 per hour and discontinues the attendant compensation rate enhancement program.
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The purpose of this amendment is to update the Texas Medicaid State Plan to reflect the permanent federal requirement for coverage of Medication-Assisted Treatment for opioid use disorder.
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The proposed amendment will update School Health and Related Services (SHARS) pages within the Reimbursement Methodologies for the Early and Periodic Screening, Diagnosis, and Treatment Comprehensive-Care Program (EPSDT-CCP) section of the state plan.
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The purpose of this amendment is to acknowledge that as of September 1, 2025, HHSC will no longer have a Superior Waiver in place under 42 CFR Part 456, subpart H, that waivers the requirements of Subpart C for all hospitals, and all mental hospitals for a state that sufficiently demonstrates utilization review procedures superior to the federal requirements. This amendment includes pages for Subpart C and Subpart D.
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The purpose of the amendment is to update Community First Choice (CFC) fees schedules and also discontinues the attendant compensation rate enhancement program.
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This SPA allows the state to cover prescribed drugs that are not covered outpatient drugs when medically necessary during drug shortages identified by the Food and Drug Administration.
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The proposed amendment updates the Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program fee schedules.
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The proposed amendment updates the Durable Medical Equipment, Prosthetics, O1ihotics, and Supplies Services fee schedules.
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The purpose of this amendment is to update Personal Care Services (PCS) reimbursement methodology.
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This plan amendment updates the physicians’ and other practitioners’ program fee schedules.
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The proposed amendment updates the Ambulatory Surgical Center reimbursement fee schedule.
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This plan amendment updates the Medicaid family planning services fee schedule with a proposed effective date of April 1, 2025.
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This plan amendment updates the physicians' and other practitioners' program fee schedules.
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This amendment make requirements for Indian Health Services and Tribal clinics consistent with the requirements set forth in 42 Code of Federal Regulations §440.90. The SPA requires a mandatory exception to the four-wall requirement for the Medicaid clinic services benefit to authorize reimbursement for clinic services provided outside of the four walls of Indian Health Services and Tribal clinics.
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The amendment accounts for rate increases in the following services: assisted living, supervised living, and supported home living.
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This plan amendment updates the physicians’ and other practitioners’ program fee schedules.
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This plan amendment updates the payment rate and rate methodology for the Pediatric Care Facility Special Reimbursement Class of Nursing Facilities.
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The amendment renews Texas’ 1915(i) State Plan HCBS benefit. The effective date for this renewal is September 1, 2025.
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This amendment adds Certified Family Partner Services as a new Texas Medicaid benefit.
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This amendment makes requirements for physical therapy services consistent with requirements for Medicaid home health services.
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The proposed amendment updates the Physicians and Other Licensed Practitioners' Services fee schedules, effective March 1, 2025.
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This plan amendment updates High-Cost Clinician Administered Drugs and Biologics (HCCADs), Human Breast Milk Processing Storage and Distribution, and Long-Acting Reversible Contraceptive devices to pay outside the all patient refined diagnosis-related group inpatient reimbursement.
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This plan amendment updates the Clinical Diagnostic Laboratory Services fee schedules (CDL), and removes language related to COVID-19 lab rates that is no longer relevant.
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This plan amendment updates the Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program fee schedules
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This amendment adds Federally Qualified Health Centers and Rural Health Clinics as providers of home telemonitoring services; clarifies that the term “home telemonitoring services” is synonymous with “remote patient monitoring;” and requires home telemonitoring providers to establish a plan of care with outcome measures for each patient and to share the plan and outcome measures with the patient’s physician.
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This plan amendment updates the Financial Management Services Agencies (FMSAs) fee schedule, effective October 1, 2024.
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The proposed amendment updates the Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program fee schedule, effective October 1, 2024.
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The amendment updates the Nonemergency Medical Transportation Demand Response fee schedule.
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The proposed amendment updates the ambulatory surgical center fee schedule, effective December 1, 2024.
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This plan amendment updates the Physician and Other Practitioners fee schedule, effective October 1, 2024.
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This amendment expands the types of providers who can provide case management for children and pregnant women (CPW) services.
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This amendment is to assure HHSC compliance with the mandatory reporting of the CMS Child Core Set and the behavioral health measures of the Adult Core Set as per Sections 1139A(a)(4)(B) and 1139B(b)(3)(B) of the Social Security Act respectively, beginning in 2024, and annually reporting in subsequent years, on all measures on the Child Core Set and the behavioral health measures in the Adult Core Set.
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The proposed amendment updates the fee schedule for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) and Vision Care Services. Fiscal impact is for reimbursements for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) and Vision Care Services effective date of September 1, 2024.
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The proposed amendment updates the Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program fee schedule, effective September 1, 2024.
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The proposed amendment updates the Clinical Diagnostic Laboratory fee schedule.
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The proposed amendment updates the physicians' and other practitioners' program fee schedule.
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This SPA amendment, the state is updating performance measures for provider qualification requirements.
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This SPA proposes to amend the State Plan to create a new, temporary non-preferred status, and establish criteria for new-to-market drugs that have not yet been reviewed by the Drug Utilization Review Board.
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The proposed amendment updates physicians' and other practitioners' program fee schedule.
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This amendment is to update the State Plan to allow providers of inpatient psychiatric hospital services in an institution of mental disease to be accredited by any CMS-approved accreditation organization for psychiatric hospitals.
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This plan amendment updates the Disproportionate Share Hospital (DSH) program reimbursement methodology and revises the DSH allotment distributed among eligible hospitals.
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This amendment updates State Plan language regarding the Community First Choice program to reduce the provider requirements for emergency response.
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This amendment is to provide children under age 19 with 12 months of continuous eligibility in Medicaid, in accordance with Section 1902(e)(12) of the Social Security Act, as amended by Section 5112 of the Consolidated Appropriations Act, 2023. Children under age 19 will remain continuously eligible for the full 12-month certification period, regardless of changes in circumstances with certain exceptions.
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This amendment is to require a Prescribed Pediatric Extended Case Center (PPECC) to provide transportation to a recipient when the recipient’s physician determines the recipient is stable to receive transportation services and the parent or legal guardian wants the recipient to receive transportation services.
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This plan amendment updates the family planning services fee schedules.
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This amendment, the state is adding home health providers (under nursing services) to its electronic visit verification (EVV) requirement policy, in accordance with §1903(i) of the Social Security Act.
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The proposed amendment updates the Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program fee schedule.
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The proposed amendment updates the fee schedule for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS).
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The proposed amendment updates the fee schedules and the Medicaid reimbursement methodology for Clinical Diagnostic Laboratory services.
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The proposed amendment updates the physicians’ and other practitioners’ program fee schedule.
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The proposed amendment updates the Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program fee schedule.
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This SPA updates language in the State Plan Pages regarding the composition of the Drug Utilization Review Board.
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The amendment documents coverage of COVID-19 vaccines and administration of the vaccines for children under the age of 21.
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This amendment is to allow certain non-drug products to be added to the pharmacy formulary.
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This amendment is to update the state's minimum personal needs allowance for individuals residing in a nursing facility (NF), assisted living facility, intermediate care facilities for individuals with intellectual disabilities (ICFs/IID), or other similar long-term care facility from $60 to $75 for individuals and from $120 to $150 for couples.
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The proposed amendment documents coverage of COVID-19 tests as a benefit in Texas Medicaid, including at-home tests provided through a pharmacy.
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This amendment is to adopt the changes to the eligibility rules for the Former Foster Care Children eligibility group, as enacted by the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act, Pub. L. No. 115-217, section 1002.
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This amendment is to update the State Plan to include Collaborative Care Model (CoCM) services, as directed by Senate Bill 672, 87^th^ Legislature, Regular Session, 2021.
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The proposed amendment updates the physicians’ and other practitioners’ fee schedules.
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The proposed amendment updates the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) fee schedules.
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This SPA provides Texas with approval to provide 12 months of continuous postpartum coverage to individuals enrolled in its Medicaid program.
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The proposed amendment updates the Home Health fee schedule.
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The purpose of the amendment is to clarify the reimbursement methodology for renal dialysis services as payable outside of the current composite rate due to new and/or expensive technology and high cost drugs.
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The purpose of the amendment is to update the rate methodology and payment rates for Personal Care Services (PCS) in support of increasing the base wage for certain personal attendants under Medicaid and other programs administered by HHSC to $10.60 per hour, in accordance with the 2024-25 General appropriations Act, House Bill 1, 88th Texas Legislature, Regular Session, 2023 (Article II, HHSC, Rider 30(a)).
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The proposed amendment updates the payment rate for the Pediatric Care Facility Special Reimbursement Class of Nursing Facilities.
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The purpose of the amendment is to update the rate methodology and payment rates for Intermediate Care Facilities (ICF) in support of increasing the base wage for certain personal attendants under Medicaid and other programs administered by HHSC to $10.60 per hour.
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The purpose of the amendment is to update the rate methodology and payment rates for Nursing Facilities (NF).
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The proposed amendment updates the rate methodology and payment rates for Primary Home Care (PHC) and Community Attendant Services (CAS) to support base wage increases for certain personal attendants. The proposed amendment also revises the initial cost report database to calculate the direct care cost component to be the most recent PHC Medicaid cost report database.
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This amendment modifies the definition of rural hospitals to reflect the population updates in the 2020 U.S. Census and increase the minimum payment for the labor and delivery add-on for rural hospitals
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The purpose of the amendment is to update the rate methodology and payment rates for Day Activity and Health Services (DAHS) in support of increasing the base wage for certain personal attendants under Medicaid and other programs administered by HHSC to $10.60 per hour and revise the initial cost report database used to calculate the direct care cost component to be the most recent DAHS Medicaid cost report database.
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The purpose of the amendment is to update the rate methodology and payment rates for Community First Choice (CFC) services in support of increasing the base wage for certain personal attendants under Medicaid and other programs administered by HHSC to $10.60 per hour.
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The proposed amendment updates the fee schedule for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) and Hearing Aids and Audiometric Evaluations.
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This amendment is to remove limitations on fee-for-service (FFS) for non-local mental health authorities and local behavioral health authorities of mental health targeted case management per recent state legislature.
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The proposed amendment updates the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) fee schedules.
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The proposed amendment updates the physicians’ and other practitioners’ fee schedules.
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The proposed amendment updates the Ambulance Services fee schedule.
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The proposed amendment updates the physicians and other practitioners fee schedules.
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The updates in the state plan benefit accounts for rate increases in the following services: assisted living and in-home respite services.
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The proposed amendment updates Ambulatory Surgical Center reimbursement methodology and fee schedules.
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The purpose of the amendment is to update the rate methodology and payment rates for Prescribed Pediatric Extended Care Centers (PPECC).
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Primarily updates the rate methodology and payment rate for STAR Kids Community First Choice (CFC) Habilitation and Attendant Care, under the Consumer Directed Services (CDS) option. Other non-substantive edits are provided for clarity.
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This amendment will create a Hospital Augmented Reimbursement Program for private hospitals to preserve the financial resources many Texas hospitals depend on to provide access and quality care to Medicaid clients.
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The proposed amendment will allow the Texas Health and Human Services Commission (HHSC) to make Medicaid Direct Graduate Medical Education payments to non-government owned or operated teaching hospitals.
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This SPA proposes to update the state's excluded drug list to include selective non-prescription drugs and other excluded drugs and list them on the state's website.
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(spa-index)(p02)Texas Medicaid state plan amendments on medicaid.gov: SPA index page 2 of 7#
(spa-index)(p02)(block-1)Medicaid State Plan Amendments#
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The proposed amendment updates the fee schedules for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies and Hearing Aids and Audiometric Evaluations.
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This amendment clarified revisions to the inflation projection methodology for the Day Activity and Health Se1vices (DAHS), 1915 Home and Community-Based Services-Adult Mental Health (HCBS-AMH), Inte1mediate Care Facilities for Individuals with an Intellectual Disability (ICF/IID), Nursing Facility (NF), and Primarily Home Cal·e (PHC) programs. A revision will also be made to the nursing wage inflation methodology, which will affect only the DAHS, HCBS-AMH, ICF/IID, and NF programs.
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This state plan amendment updates the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) services fee schedule.
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(spa-index)(p03)Texas Medicaid state plan amendments on medicaid.gov: SPA index page 3 of 7#
(spa-index)(p03)(block-1)Medicaid State Plan Amendments#
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Modifies the reimbursement methodology in the state plan for certain 1915(i) (HCBS) by requiring biennial, rather than annual, cost reports from providers.
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This amendment expands the needs based-eligibility criteria for the Home and Community-Based Services - Adult Mental Health (HCBS-AMH) 1915(i) programs to include adults with a diagnosis of a serious mental illness (SMI) who have a history of psychiatric crisis and repeated discharges from correctional facilities, as well as adults with a diagnosis of SMI who have a pattern of emergency department utilization.
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(spa-index)(p04)Texas Medicaid state plan amendments on medicaid.gov: SPA index page 4 of 7#
(spa-index)(p04)(block-1)Medicaid State Plan Amendments#
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The purpose of this amendment Is to clarify state plan requirements related to the Early and Periodic Screening, Diagnosis, and Treatment Eyeglass Program and the Medicaid Vision Care Program for Individuals age 21 and older.
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Implements the Community First Choice (CFC) program under section 1915(k) of the Social Security Act. CFC services would be provided to individuals who meet categorical coverage requirements for Medicaid or meet financial eligibility for home and community-based services and who meet an institutional level of care.
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Adjusts the payment rates for the Day Activities and Health Services (DAHS) program to be equal to the payment rates in effect on August 31, 2014 plus an additional $0.15 increase to the base rate.
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Adjusts the Primary Home Care (PHC) non-priority attendants cost payment rates to be equal to the payment rates in effect August 31, 2014 plus an additional $0.39.
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This amendment updates the fee schedule for physicians and other practitioners and add telemonitoring as an advanced telecommunication service.
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Updates the Physicians' and other practitioners' fee schedules.
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Updates the fee schedule for home health and durable medical equipment, prosthetics, orthodontics and supplies.
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Updates the fee schedule for home health professional services, durable medical equipment, prosthetics, orthotics and supplies and includes telemonitoring as a telehealth service.
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(spa-index)(p05)Texas Medicaid state plan amendments on medicaid.gov: SPA index page 5 of 7#
(spa-index)(p05)(block-1)Medicaid State Plan Amendments#
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This state plan amendment adds licensed direct-entry midwives as a payable provider type in the birthing center setting.
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This state plan amendment limits the payments for Medicare Part B services for the dual eligible population to no more than the state plan rate, with the exception of renal dialysis services. The state plan amendment also changes the monthly capitation payment for Medicare Part C services to $10 per member per month.
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Form CMS-179
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Form CMS-179
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Form CMS-179
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Form CMS-179
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Form CMS-179
This amendment implements a rate reduction to the fixed component of the dispensing fee paid to Medicaid pharmacy providers. It reduces the dispensing fee from $7.35 to $6.50.
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The purpose of this amendment is to delete the pages in the Texas state plan governing the methodology for computing inpatient, outpatient, and physician supplemental Medicaid payments, also called the Upper Payment Limit (UPL) program.
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Form CMS-179
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Form CMS-179
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Form CMS-179
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(spa-index)(p06)Texas Medicaid state plan amendments on medicaid.gov: SPA index page 6 of 7#
(spa-index)(p06)(block-1)Medicaid State Plan Amendments#
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Form CMS-179
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This amendment specifies that the interim reimbursement rate paid for mental health rehabilitation services which was in effect on September 30, 2007, will remain in effect until August 31, 2010.
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Revises the Reimbursement Methodology for Day Activity Health Services DAHS.
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Updates Physician Services Fee Schedule for Fees Paid to Physicians Certain Practitioners.
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Clarifies the eligibility criteria for extended Medicaid benefits.
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(spa-index)(p07)Texas Medicaid state plan amendments on medicaid.gov: SPA index page 7 of 7#
(spa-index)(p07)(block-1)Medicaid State Plan Amendments#
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Updates the fee schedule for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies.
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Adds language to allow coverage of a new preventive services benefit and clarifies language to more accurately align the state plan with current Texas Medicaid policies.
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Modifies Reimbursement Methodology for In-Home Total Parenteral Hyperalimentation Services.
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Form CMS-179
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