Txhml Billing Guidelines

Texas Department of Mental Health and Mental Retardation

TEXAS HOME LIVING(TxHmL) PROGRAM

SERVICE DEFINITIONS&

BILLING GUIDELINES

February 2004

TDMHMR Texas Home Living (TxHmL) Waiver ProgramSERVICE DEFINITIONS AND BILLING GUIDELINES

TxHmL Service Definitions and Billing GuidelinesFebruary 2004

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Section I: General Instructions--TxHmL Service Definitions and BillingInstructions

Billable Time/Activities

Billable time and activities are discussed separately for each service component. Pleaserefer to the specific section of the billing guidelines for an explanation of billabletime/activities for each service component.

General Non-Billable Time/Activities

Time spent in each of the following activities is non-billable and apply to every servicecomponent. The cost of these activities, except the activities followed by an asterisk (*),are included in the service component rates for billable activities. The activities followedby an asterisk (*) are not reimbursable under federal law or regulation.

• Staff travel time• Documenting service delivery/service monitoring, writing individual treatment

plans, processing paperwork, completing records, or entering data• Participating in employee conferences and/or evaluations• Filing claims for reimbursement• Providing services during a period of temporary discharge of an individual *• Receiving training during staff development activities, continuing education or

professional conferences• Collateral contacts regarding services or service needs which are not related to the

delivery of specific services to an individual• Services delivered while an individual is in a hospital or other institution*• Services provided prior to the effective date of an individual's enrollment*• Collateral contacts between professional staff/consultants of the TxHmL provider

occurring outside the context of a service planning team meeting

Qualified Service Providers

All service components must be provided by personnel meeting the minimumqualifications to provide that service as specified in the TxHmL Program Rules, Chapter419, subchapter n,§419.579.



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Relatives and Guardians as Service Providers

Reimbursement for TxHmL program services that are provided to an individual byhis/her relatives or guardian is not allowed under the following circumstances:

• TxHmL services and supports provided to a minor child by his/her natural,adoptive or step-parents, by his/her Texas Department of Protective andRegulatory Services foster parent(s), or by a person(s) financially responsible forthe minor child.

• TxHmL services and supports provided to an individual by his/her spouse.

• Behavioral Support, or Adaptive Aids provided to an individual by his or herguardian or by a person related to the individual within the fourth degree ofconsanguinity or within the second degree of affinity.*

• Persons who live with the individual, whether related to the individual or not, maynot be paid to provide Community Support, Respite Care, or Adaptive Aids to theindividual.

*Degree of Relationship. Two individuals are related to each other by consanguinity ifone is a descendant of the other or they share a common ancestor. An adopted child isconsidered to be a child of the adoptive parent for this purpose. Two individuals arerelated by affinity if they are married to each other or the spouse of one of the individualsis related by consanguinity to the other individual. The ending of a marriage by divorceor the death of a spouse ends relationships by affinity created by that marriage unless achild of that marriage is living, in which case the marriage is considered to continue aslong as a child of that marriage lives. The following chart lists relationships within thefourth degree of consanguinity and within the second degree of affinity.



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DEGREE OF CONSANGUINITY OR AFFINITY

CONSANGUINITY

FIRSTDEGREE

SECONDDEGREE

THIRDDEGREE*

FOURTHDEGREE*INDIVIDUAL

ChildParent

GrandchildSister/BrotherGrandparent

Great-grandchild

Niece/NephewAunt/Uncle

Great-grandparent

Great, great-grandchild

grandniece/nephew

First CousinGreat Aunt/Uncle

Great, greatgrandparent

AFFINITY

FIRSTDEGREE

SECONDDEGREE

INDIVIDUAL Spouse

Mother-in-lawFather-in-lawSon-in-law

Daughter-in-law

StepsonStepdaughterStepmotherStepfather

Brother-in-lawSister-in-law

Spouse'sgrandparent

Spouse'sgrandchild

Grandchild'sspouse

Spouse ofgrandparent

* These relatives and the individual must share a common ancestor. For example,the individual would not be related within the third degree of consanguinity to anuncle who is the spouse of the individual's father's sister. The individual wouldbe related within the third degree of consanguinity to an uncle who is thebrother of the individual's father.



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Definitions:

Service Event: A service event is one or more billable activities that take place within aspecific time period to provide a specified service component. A service event starts atthe beginning of a billable activity and ends with the completion of a billable activity.

Written Narrative: A written description of service events provided to an individual onan hourly or daily basis and periodically addresses progress made toward goals andobjectives.

Summary: A brief account of the Day Habilitation provided to an individual during acalendar week and periodically addresses progress toward goals and objectives.

Daily Log: Written documentation that provides a daily record of the actual begin andend times of Day Habilitation.

Billing Log: Written documentation that provides a record of transportation serviceevents when transporting one or more individuals by one or more service providers.

Calendar Week: Sunday through Saturday.

Calendar Day: 12:00 am through 11:59 pm.

Calendar Month: January, February, March, April, May, June, July, August, September,October, November, December.

Non-Routine Social Event: A social happening that is out of the ordinary, such as abirthday party, a Valentine dance, etc. that occurs away from the individual’s residence.

Begin and End Time: The exact time the service event was initiated and the exact timethe service event was completed.

Consecutive 24-Hour Period: A continuous 24-hour period that may span two calendardays.

Collateral Contact: An entity other than the consumer from which informationregarding the consumer may be gained.



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Minimum Documentation Requirements for Billing

The program provider must document the delivery of all TxHmL service components toan individual for which a claim has been paid. At a minimum, documentation for eachservice event claimed for reimbursement must contain the following information:

Name of the individual,Type of service,Place of service,Date of service (month, day, year),Actual begin and end time for any service event billed,Service(s) delivered, described in enough detail to explain the service(s),Name and title of qualified service provider delivering service, andSignature of the service provider.

A sample service delivery form has been included and may be modified to meet aprogram provider’s need. However, a service delivery form must include the minimumdocumentation requirements listed above. Please refer to the Table of Contents for thesample Service Delivery Log.

Service Event

A service event is one or more billable activities that take place within a specific timeperiod to provide a specified service component. A service event starts at the beginningof a billable activity and ends with the completion of a billable activity. With theinitiation of each new service event there must be supporting documentation for the newservice event. For example, if one service event ends at 10:30 am and another serviceevent for the same service component begins at 11:00 am, each service event must bedocumented separately with a written narrative. Whether two staff or the same staffperson provides the service event, a written narrative is required for each service event.Written documentation of service events is required for all service components regardlessof whether they are billed hourly or daily. Service events for activities that are billed inhourly units of service or daily units of service must have begin and end times. Begin andend times document the actual duration of the service event.

Service events must be documented separately for each service component. It is notpermissible to combine service events for two or more service components into onewritten narrative.



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Written Narrative

Written narratives developed by the actual service provider are used to document thedelivery of each service event. For billing purposes, the written narrative verifies thedelivery of the service event. The written narrative is a record of the contact with theindividual or with collateral and how the activities that were provided relate to the serviceoutcomes addressed in the PDP. Written narratives must contain the “MinimumDocumentation Requirements for Billing” listed above. In addition, each servicecomponent included in the billing guidelines specifies the minimum frequency for writtennarratives.

Depending on the activities provided during a service event, the written narrative may bea brief statement summarizing the services provided to the individual. For example, if theservice being provided is Community Support and the activity involves bathing theindividual, brushing the individuals teeth, and preparing them for bed, the writtennarrative may be limited to a brief description of the activities that were provided duringthe service event for which the program provider expects reimbursement. The writtennarrative must include pertinent information about the individual’s progress toward theservice outcomes outlined in the PDP when the service event involves the collection andevaluation of service outcomes. The written narrative should also include any informationabout unique circumstances that may have occurred during the service event, i.e. seizures,behavioral outbursts, illness, etc. The written narrative must also include where theservice was provided (place of service).

Written narratives must document unusual and significant circumstances or events at thetime these occur and the actions taken by the provider. For example, written narrativesshould record the injury or illness of a individual, events disrupting service delivery orrequiring additional service delivery, or other events which affect service delivery or thehealth, safety and welfare of an individual.

Written narratives that are documented with ditto marks or brief statements that do notprovide sufficient detail to explain the billable activity(s) do not satisfy the billingdocumentation requirements. For example, statements such as “had a good day”, “went toschool”, “no problem today”, “did ok”, etc., are not sufficient to satisfy thedocumentation requirements and will result in the billing claim being denied and thepayment being recouped. Written narratives that are repeated, duplicated, or photocopiedthat are identical to previously written narratives are not sufficient and will also result inpayment being recouped.



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Supplemental billing documentation will not satisfy the billing documentationrequirements. Supplemental billing documentation includes:• data collection sheets,• staff time sheets,• schedules,• check off sheets,• photocopied pre-completed written/printed forms/notes

A written narrative must be completed after the service is delivered and must alwaysprovide sufficient detail to explain the activity(s) that occurred during the service event.Each written narrative must be unique.

Written narratives must be maintained to sufficiently document the provider’scompliance with the TxHmL Certification Principles. When appropriate, the writtennarrative should state the progress or lack of progress toward the service outcomesaddressed in the PDP.

Written Summary

A written summary is similar to a written narrative, but is used to document DayHabilitation when the program provider chooses to document service delivery on aweekly basis. The written summary is developed by the service provider and gives a briefaccount (summary) of the Day Habilitation activities provided to the individual during acalendar week and when the service event involves the collection and evaluation ofservice outcomes addresses progress toward goals and objectives. A calendar weekalways begins with Sunday and continues through that Saturday. The written summary isintended to summarize all of the services provided during the calendar week into onesummary statement for that week.

Written summaries must be maintained to sufficiently document the provider’scompliance with the TxHmL Certification Principles. When appropriate, the writtensummary should state the progress or lack of progress toward the service outcomesaddressed in the PDP.



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Rounding Rules for Services Billed in 15 Minute Units

The billable unit of service is 15 minutes for Respite (when provided on an hourly basis),Nursing, Specialized Therapies, Community Support, Employment Assistance, BehaviorSupport and Supported Employment components. A 15-minute unit of services is billedfor the service component based on the following rounding rules.

Billable Unit of Service Actual Direct Service Time

1 unit 8 minutes - 22 minutes

2 units 23 minutes - 37 minutes



Converting Service Time to Billable Units

The formula for calculating service time and billed units for a service component havinga unit of service of 15 minutes is:

# of Providers X Length of service ÷ # of individuals = service time per individual =Billable units of service.

• The number of providers is multiplied by the minutes of service provided and thendivided by the number of individuals served.

• The resulting number represents the service time per individual prior to applying therounding rules.

• Apply the rounding rules and convert the minutes to service time and billable units ofservice.

• A table follows that provides examples of how the billable units per individual iscalculated.



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# ofProviders X

Length ofservice ÷

# ofindividuals =

service timeper individual =

billableunits ofservice

1 X 20 min. ÷ 3 = 6.66 min = 0 units1 X 30 min. ÷ 2 = 15 min = 1 unit

1 X 45 min. ÷ 4 = 11.25min = 1 unit

1 X 60min. ÷ 1 = 60 min = 4 units

1 X 60min. ÷ 2 = 30 min = 2 units

1 X 60min. ÷ 3 = 20 min = 1 unit

2 X 120 min. ÷ 6 = 40 min = 3 units

Exceptions: The only exceptions for billing services with a 15-minute unit of serviceoccur when Respite or Community Support transportation is provided. When Respite isprovided to more than one individual, and billed in 15-minute units of service, providersshould not use the above formula to divide the service time by the number of individualsbut should bill the actual time each individual received respite. Please refer to Section IIof the guidelines that address Community Support when billing for individualtransportation.

Billing Multiple Services Simultaneously

In some cases, two services covering the same time period may be billed if both servicesare actually delivered simultaneously. For example, an Occupational Therapist observesand assesses an individual's gross and fine motor skills while the individual performsspecific tasks at the Day Habilitation site. In this instance the Occupational Therapist isassessing the individual while the individual is participating in the Day Habilitationprogram. The individual is clearly the recipient of both Day Habilitation andOccupational Therapy services and both may be billed simultaneously. In anotherexample, a nurse visits a Day Habilitation program and has an individual accompany herto another office where she administers medication to the individual. In this case, theindividual is not receiving two services simultaneously; at the time the individual isreceiving the medication, Day Habilitation services are not being provided.Consequently, the individual should sign out of the Day Habilitation activity whilereceiving the Nursing service and sign back in when he/she resumes participation in theDay Habilitation activity.



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Community Support

Component Definition:

The Community Support service component provides services and supports in aparticipant’s home and at other community locations that are necessary to achieveoutcomes identified in the participant’s person-directed plan. This component provideshabilitative or support activities that provide, foster improvement of, or facilitate anindividual’s ability to perform functional living skills and other activities of daily living.Habilitative or support activities are provided that foster improvement of or facilitate anindividual’s ability and opportunity to participate in typical community activities,including activities that lead to successful employment; to access and use available non-waiver program services or supports for which the participant may be eligible; and toestablish or maintain relationships with people who are not paid service providers thatexpand or sustain the participant’s natural support network. The community supportcomponent provides assistance with medications and the performance of tasks delegatedby a Registered Nurse in accordance with state law. This component does not includepayment for room or board and may not be provided at the same time that the hourly-reimbursed Respite, Day Habilitation, or Supported Employment service component isprovided.

Community Support Billable Time/Activities:

• Face-to-face contact with the individual to provide Community Support in theindividual’s home or at other community locations.

• Face to face contact with family member(s) necessary to achieve outcomes in anindividual’s Person Directed Plan (PDP).

• Telephone contact with the individual or family member when an emergency arisesthat directly affects the individual, i.e., seizure, injury, or other major crises, that ismore expediently handled by telephone than in person.

• Activities that do not include face-to-face or telephone contact with the individual butthat are necessary to directly support a specific individual, e.g., meal preparation,shopping, etc. As the intent of the TxHmL program is community integration, billingfor activities that do not include face-to-face or telephone contact must be minimizedand justification for the activity must be included in the written narrative.

• An individual’s participation in volunteer services may be considered CommunitySupport if the outcome to be achieved by the service is consistent with theCommunity Support component definition and the individual’s PDP.

• Participation in service planning team meetings.



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Community Support Billable Time/Activities Continued:

• An individual’s participation in activities provided in an adult educational setting(college, GED course) may be considered Community Support if the outcome to beachieved by the service is consistent with the Community Support componentdefinition and the individual’s PDP.

• Providing transportation for an individual to and from home directly to theindividual’s community employment site or day habilitation site and transportation tofacilitate the individual's employment opportunities and participation in communityactivities.

• Habilitation activities that include, but are not limited to, training in self help andindependent living skills, implementation of programs developed by a licensedtherapist, and implementation of programs to develop appropriate social behaviors.

Community Support Non-billable Time/Activities:

• Community Support delivered in an HCS group home or Foster/Companion Carehome for the convenience of the service provider or the program provider.

• Community Support provided by a service provider who is simultaneously providingHCS Residential Support, Supervised Living, or Foster/Companion Care.

• Habilitation activities provided and billed as part of the Day Habilitation servicecomponent.

• Community Support may not be billed simultaneously with hourly respite or on thesame calendar day that daily respite is provided.

• Providing transportation for individuals from one day habilitation/supportedemployment site to another or during the time Day Habilitation is being billed.

• Community Support may not be billed when the purpose of the service is to provideplanned or emergency relief of the unpaid caregiver (this is considered respite).

• Community Support (including transportation) provided by someone who lives withthe individual.

• Community Support services not provided according to the frequency and amountagreed upon and approved by the Service Planning Team. This includes service unitsprovided in excess of what has been authorized on the PDP when documentation doesnot exist to support the additional provision of services.



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Community Support Non-billable Time/Activities Continued:

• Community Support may not be billed when staff assistance is not needed by anindividual to achieve goals or outcomes, complete personal care, maintain healthand independent living skills, participate in community activities, or develop,retain, and improve community living skills.

• Community Support provided simultaneously with Day Habilitation services.

• Provision of Community Support when face-to-face or telephone contact is notmade with the individual and justification for the activity is not included in thewritten narrative.

Unit of Service: 15 minutes



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Calculating Billing for Community Support When Transporting 2 or MoreIndividuals:Transportation for Community Support may be calculated by one of the two methodslisted below. The method selected by the program provider must be implementedconsistently for all Community Support transportation activities. Program providers mustchoose and use one method consistently. Every person being transported must beincluded in the calculation to derive the billable time per person (not just the TxHmLindividuals). A written narrative or billing log that meets the Community Supportdocumentation requirements must be completed after each transportation event.

The procedure for calculating billing follows:

Number of service providers (SP) multiplied by minutes for transportation event (TE)divided by the number of individuals (IND) transported equals the billable time for eachindividual (BT).

**The formula for calculating billing is: # of SP X #min of TE ÷ # of IND = BT

Method 1: Providers may choose to consider the start time of the service event as thetime the first individual is picked up and the end time as the time thegroup of individuals reaches its destination. The duration of the totalservice time is multiplied by the number of staff transporting and thendivided by the number of individuals transported. For example, individualA is picked up by the provider at 8:15 a.m., individual B is then picked upat 8:20 a.m., individual C is picked up at 8:30 a.m. The three individualsreach the Day Habilitation activity at 8:45 a.m. The total duration of theservice event is 30 minutes. The billable time for each individual would be10 minutes or 1 unit of Community Support.

Method 2: As an alternative to the above procedure, Community Support providersmay choose to calculate the actual time for each individual. For example,one individual is transported by one service provide for 15 minutes until asecond individual is picked up. The two individuals are transported foranother 1 hour. The provider could consider this activity as two distinctservice events. The first service event would involve one individual andthe billable time would be 15 minutes or 1 unit. The second service eventwould involve two individuals and, when group billing guidelines areapplied, the billable time for each individual would be 30 minutes or 2units.

**NOTE: This formula and methods should also be utilized when calculatingCommunity Support provided to 2 or more individuals at the same timein a setting other than for the purpose of transportation.



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Calculating Billing for Community Support When Transporting 2 or MoreIndividuals Continued:

Accumulate: Regardless of which method (1 or 2 above) is used, transportation timemay be accumulated for each individual over the course of a single dayeven if more than one Community Support provider transports individualsduring the day. For example, a Community Support provider transports agroup of six individuals for 40 minutes in the morning to a DayHabilitation site and a second Community Support provider transports thesame group home from the Day Habilitation site in the afternoon. As thebillable time for each individual for the morning trip is 6 minutes (basedon rules for billing services and rounding rules), the provider would beunable to bill 1 unit of service for any of the six individuals as the billabletime is less than eight minutes. The same scenario would apply in theafternoon. However, in this example, if the provider chooses toaccumulate the time spent in transporting the individuals over the courseof the morning and afternoon, the accumulated time is 13.33 minutes perindividual and 1 unit of service would be billed for each of the sixindividuals for the day.



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Community Support Documentation Requirements:

A written narrative for each Community Support service event that describes the serviceand when appropriate includes information pertaining to the individual’s progress towardgoals and outcomes.

Each written narrative must include:• Name of individual• Place of service• Type of service• Date of service (month, day, year)• Actual begin and end time of service event• Detailed description of service provided• Name and title of service provider• Signature of service provider per service event

When documenting transportation provided to one or more individuals by one or moreservice providers, a billing log** may be substituted for a written narrative.

The billing log must include:• Name of individual• Type of service• Method selected for calculating billing• Date of service (month, day, year)• Actual begin and end time• Number of individuals transported• Number of providers• Destination (to and from)• Name and title of service provider• Signature of service provider

**For a sample billing log that includes all the components listed above seeAppendix A.**



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Specialized Therapies


The specialized therapies service component provides assessment and treatment bylicensed occupational therapists, physical therapists, speech and language pathologists,audiologists, and dieticians and includes training and consultation with an individual’sfamily members or other support providers.

Specialized Therapies Billable Time/Activities:

• Face-to-face contact with an individual to conduct assessments or providetherapy.

• Face-to-face or telephone contact with a physician (including a psychiatrist)regarding the therapy provided to a specific individual.


• Training provided to direct service providers or family members responsible forperforming, monitoring, reporting and documenting a specific individualtreatment plan for a specific individual.

• Face-to-face or telephone contact with individuals or their family members orother service providers (excluding licensed/certified staff employed or contractedby the TxHmL program provider and service coordinators) necessary for theprovision of a specific service to a specific individual.

• Private insurance co-payments for therapies may be reimbursed to the nearestnumber of units that do not exceed the co-payment amount.

Specialized Therapies Non-Billable Time/Activities:

• Developing and monitoring individualized treatment plans, individualized menus,therapy schedules, etc.

• Delivery of or supervision of services or tasks outside the scope of professionalcertification/licensure; for example, supervising an individual, providing personalcare, or scheduling appointments.

• Providing transportation for an individual.

• Travel time or time spent waiting to provide services.



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Specialized Therapies Non-Billable Time/Activities Continued:

• Providing training for other service providers related to general procedures ortopics, e.g., training in the general principles of the specialized therapy, generalcare of adaptive aids and equipment.


Specialized Therapies Documentation Requirements:

A written narrative for each service event that describes the service and when appropriateincludes information pertaining to the individual’s progress toward goals and objectives.

The written narrative must include:• Name of individual• Type of service• Date of service (month, day, year)• Place of service• Actual begin and end time of each billable service event• Detailed description of the service event• Name and title of service provider• Signature of service provider

For co-payment reimbursement, a program provider must maintain the followingdocumentation:

• a copy of the policy specifying that a co-payment must be made by thepolicyholder;

• a receipt that verifies payment of the co-payment by the policy holder;• an explanation of benefit (EOB) regarding the counseling and therapies

sub-component provided to the individual from the insurance companythat issued the policy, showing that co-payments were required by thepolicyholder.



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Behavioral Support


The Behavioral Support service component provides specialized interventions that assista participant to increase adaptive behaviors to replace or modify maladaptive or sociallyunacceptable behaviors that prevent or interfere with the participant’s inclusion in homeand family life or community life. The component includes assessment and analysis ofassessment findings of the behavior(s) to be targeted so that an appropriate behavioralsupport plan may be designed; development of an individualized behavioral support planconsistent with the outcomes identified in the participant’s person-directed plan; trainingof and consultation with family members or other support providers and, as appropriate,with the participant in the purpose/objectives, methods and documentation of theimplementation of the behavioral support plan or revisions of the plan; monitoring andevaluation of the success of the behavioral support plan implementation; andmodification, as necessary, of the behavioral support plan based on documentedoutcomes of the plan’s implementation.

Behavioral Support Billable Time/Activities:

• Face-to-face contact with an individual to conduct assessments or providespecialized interventions to increase adaptive behaviors, replace or modifymaladaptive or socially unacceptable behaviors.

• Face-to-face or telephone contact with a physician (including a psychiatrist)regarding the behavioral support provided to a specific individual.


• Training provided to direct service providers or family members responsible forperforming, monitoring, reporting and documenting a specific individualbehavioral support plan for a specific individual.

• Face-to-face or telephone contact with individuals or their family members orother service providers (excluding licensed/certified staff employed or contractedby the TxHmL program provider and service coordinators) necessary for theprovision of a specific service to a specific individual.

• Private insurance co-payments for therapies may be reimbursed to the nearestnumber of units that do not exceed the co-payment amount.



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Behavioral Support Non-Billable Time/Activities:

• Developing and monitoring individualized behavioral support plans.

• Delivery of or supervision of services or tasks outside the scope of professionalcertification/licensure; for example, supervising an individual, providing personalcare, or scheduling appointments.


• Travel time or time spent waiting to provide services.

• Providing training for other service providers related to general procedures ortopics, e.g., training in the general principles of behavior intervention or therapy.


Behavioral Support Documentation Requirements:



For co-payment reimbursement, a program provider must maintain the followingdocumentation:

• a copy of the policy specifying that a co-payment must be made by thepolicyholder;

• a receipt that verifies payment of the co-payment by the policy holder;• an explanation of benefit (EOB) regarding the counseling and therapies

sub-component provided to the individual from the insurance companythat issued the policy, showing that co-payments were required by thepolicyholder.



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Employment Assistance


The Employment Assistance service component helps a participant to locate paidemployment in the community by assisting the participant to identify his or heremployment preferences, his or her job skills, his or her requirements for the work settingand work conditions, and prospective employers offering employment compatible withthe participant’s identified preferences, skills, and requirements. This service componentfacilitates the participant’s employment by contacting prospective employers on behalf ofthe participant and negotiating the participant’s employment.

The participant’s service planning team must approve continuation of EmploymentAssistance every 180 days.

Employment Assistance furnished under the waiver is not available under a programfunded by either the Rehabilitation Act of 1973 or P.L. 94-142. Documentation will bemaintained in the file of each participant receiving Employment Assistance verifying thatsuch assistance is not otherwise available to the participant under a program funded underthe Rehabilitation Act of 1973, or P.L. 94-142.

Employment Assistance Billable Time/Activities:

• Face to face contact with an individual to provide employment assistance thatidentifies the individual’s skills, preferences, and requirements for employment.

• Face to face or telephone contact with an individual’s LAR to facilitate theindividual’s employment.

• Face to face or telephone contact with a prospective employer on behalf of anindividual to negotiate the individual’s employment.


Employment Assistance Non-billable Time/Activities:

• Employment Assistance provided when an individual is independently employed inthe community unless the PDP has identified outcomes for the individual to find moresuitable employment.

• Services provided when an individual is competitively employed at a SupportedEmployment site unless the PDP has identified outcomes for the individual to findmore suitable employment.



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Employment Assistance Non-billable Time/Activities Continued:

• Habilitation activities provided and billed as part of the Day Habilitation orCommunity Support service component.


• Travel time or time spent waiting to provide a service.

• Face-to-face contact with an individual to provide Employment Assistance servicessimultaneously with Day Habilitation services, Supported Employment, CommunitySupport or hourly Respite.

• Reviewing records or any other documentation regarding the individual.

• Employment Assistance provided without an individual’s service planning team re-authorizing the service after the expiration of the previous 180-day authorization.

• Employment Assistance services accessed and/or funded through other sources at nocost to the TxHmL provider. Examples include, but are not limited to, servicesprovided to an individual through the Texas Rehabilitation Commission, the publicschool system, Medicaid Rehabilitative Services for Persons with Chronic MentalIllness, senior citizen centers, volunteer programs, or other community-based sources.




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Employment Assistance Documentation Requirements:





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Nursing


Nursing includes treatment and monitoring of health care procedures prescribed by aphysician/medical practitioner and/or required by standards of professional practice orstate law to be performed by licensed nursing personnel. Registered Nurses or LicensedVocational Nurses provide nursing.

Nursing Billable/Time Activities:

• Face-to-face and telephone contact with an individual to provide nursing care,health condition monitoring/assessment, and/or medication administration andmonitoring.

• Participating in service planning team meetings.

• Training of non-licensed personnel by a Registered Nurse in the performance,monitoring, reporting, and documentation of prescribed health/medicalinterventions for a specific individual (tasks which require delegation by anRN).

• Direct supervision of delegated tasks by the Registered Nurse, as specified in thedelegation plan for the individual.

• Training of non-licensed personnel conducted by a licensed nurse (RN or LVN) inthe performance, monitoring, reporting and documentation of health/medicalinterventions for a specific individual (tasks which do not require delegation byan RN).

• Face-to-face or telephone contact with a physician (including a psychiatrist)regarding the health/medical condition of a specific individual.

• Face-to-face or telephone contact with family members, other health careproviders or service providers (excluding licensed/certified staff employed orcontracted by the TxHmL program provider and service coordinators) regardingthe health/medical condition of a specific individual.

Nursing Non-billable Time/Activities:

• Delivery of delegated health/medical care tasks by an unlicensed service provider.

• Developing and monitoring individual health care plans.



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Nursing Non-billable Time/Activities Continued:

• Delivery of or supervision of services or tasks not requiring the credentials of alicensed nurse; for example, supervision of an individual, providing personal care toan individual, or transporting/accompanying an individual to a physician’sappointment.

• Arranging medical appointments.


• Travel time or time spent waiting to provide a nursing service.

• Providing training on illness, injury, healthcare interventions, etc., applicable to thegeneral individual population (such as CPR, first aid, infection control).

• Providing nursing services without established and documented medical necessity.

• Documenting the provision of services and medication/treatment administration (suchas written narratives, the Medication Administration Record, assessment forms).

• Preparing treatments or medication for administration (non-direct services),controlling medications (storage, counting, etc.), or reviewing individual records.

• Reordering, refilling, or delivering medications.

• Face-to-face or telephone contact with licensed professional staff or contractedconsultants of the TxHmL program provider regarding the health/medical conditionof a specific individual outside the context of a service planning team meeting.




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Nursing Documentation Requirements:

A written narrative for each service event that specifies the service event performed andincludes observations of the health status of the individual (when task involves face toface contact with individual) and when appropriate, includes information pertaining to theindividual’s progress toward goals and outcomes.

The written narrative must include:• Name of individual• Type of service• Date of service (month, day, year)• Place of service• Actual begin and end time of each service event• Detailed description of the service event• Name and title of service provider• Signature of service provider per service event

NOTE: In typical nursing practice, nursing services such as medication administration,vital signs monitoring, telephone calls and conversations reporting or receiving medicalinformation, etc., require less than 8 minutes. When the duration of a single service eventis 8 minutes or more, the written narrative must clearly describe the factors requiring anextended delivery time for that service event.



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Day Habilitation


The Day Habilitation service component provides participants assistance with acquiring,retaining, or improving self-help, socialization, and adaptive skills necessary to livesuccessfully in the community and participate in home and community life. DayHabilitation provides participants with individualized activities consistent with achievingthe outcomes identified in the participant’s person-directed plan and activities designed toreinforce therapeutic outcomes targeted by other waiver service components, school, orother support providers. Day Habilitation is normally furnished in a group setting otherthan the individual’s residence for up to 6 hours a day, five days per week on a regularlyscheduled basis. Day Habilitation does not include services that are provided underSection 110 of the Rehabilitation Act of 1973 or Section 602(16) and (17) of theIndividuals with Disabilities Education Act.

Day Habilitation includes personal assistance for participants who cannot manage theirpersonal care needs during the day habilitation activity and assistance with medicationsand the performance of tasks delegated by a registered nurse in accordance with statelaw. This component also provides transportation during day habilitation activitiesnecessary for the individual’s participation in those activities. Day Habilitation may notbe provided to a participant at the same time Supported Employment, hourly-reimbursedRespite, or Community Support is provided.

Day Habilitation Billable Time/Activities:

• Face-to-face contact with the individual to provide day habilitation activities asdescribed in the Day Habilitation component definition. Day Habilitation may beprovided in a vocational setting, such as a sheltered work-site, if the outcome tobe achieved by the service is consistent with the Day Habilitation componentdefinition and the individual’s PDP.

• Face to face contact with the individual to provide day habilitation activities at theindividual’s residence if the service planning team has justified in writing allreasons that contraindicate an individual’s participation in day habilitation awayfrom the home. Provision of day habilitation at an individual’s residence may beappropriate when the individual is unable to participate in activities away fromhome due to a current medical condition or to a challenging behavior(s) whichpreclude the individual’s participation outside of the home.

• Face-to-face time spent in evaluations/assessments with a specific individual(with or without their representatives present) related to the provision of dayhabilitation.



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Day Habilitation Billable Time/Activities Continued:


• An individual’s participation in volunteer services as a part of a scheduled groupactivity may be considered Day Habilitation if the outcome to be achieved by theservice is consistent with the Day Habilitation component definition and theindividual’s PDP.

• Providing transporting to an individual between day habilitation sites.

• An individual’s participation in summer camp or day care activities paid for (inwhole or in part) by the program provider if the outcome to be achieved by theindividual’s participation is consistent with the Day Habilitation componentdefinition and the individual’s PDP addresses the specific need and the personnelproviding Day Habilitation meet the minimum provider qualifications.

Day Habilitation Non-Billable Time/Activities:

• An individual’s participation in day activities funded through other sources at nocost to the program provider. Examples of such activities include, but are notlimited to, services provided to an individual through the Texas RehabilitationCommission, the public school system, Day Activity and Health Services (DAHS)program, Medicaid Rehabilitative Services for Persons with Chronic MentalIllness, senior citizens' centers, Early Childhood Intervention program, andvolunteer programs or other community-based sources.

• Day Habilitation may not be billed when an individual refuses to participate in aday habilitation activity unless documentation supports the individual was offeredalternative activities throughout the day.

• Staff time spent providing transportation to an individual between the individual'shome and the day habilitation site.

• Staff time spent receiving in-service training.

• Day Habilitation activities provided more than 5 days in any calendar week(Sunday through Saturday).

• Time spent addressing outcomes to increase or retain vocational skills (forexample: an individual’s outcome to increase the production of an item would notbe considered Day Habilitation).



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Day Habilitation Non-Billable Time/Activities Continued:

• Time spent by an individual receiving other services that do not allow theindividual to participate in the day habilitation activity (e.g., doctor appointments,consultations with or treatments by therapists). If during the Day Habilitationactivity, another service is provided to the individual that prevents the individual’sparticipation in the Day Habilitation activity, the amount of time the individualreceives the other service must not be considered as time spent in the DayHabilitation activity (the individual “logs out” of Day Habilitation for that timeperiod and “logs backs in” Day Habilitation when the other service is completed.)

Unit of Service: 1 unit per day up to 5 days per week

Billable Service Units: Quarter unit increments (Rounding rules DO NOT apply)

Minimum Direct Service time for Billing:

Quarter Unit (.25) 1 hour and 15 minutes of consecutive direct service provisionHalf Unit (.50) 2 hours and 30 minutes of consecutive direct service provisionThree-quarter Units (.75) 3 hours and 45 minutes of direct service provisionOne Unit (1.0) 5 hours of direct service provision

Direct service time excludes transportation time between the individual's residence andthe day habilitation site.



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Day Habilitation Documentation Requirements:

Program providers must choose to document the provision of Day Habilitation on aweekly or a daily basis.To document on a weekly basis, program providers must maintain a weekly summary anda daily service log. The weekly summary describes the services provided during the weekand includes statements regarding the individual’s progress toward the goals andoutcomes for day habilitation included in the PDP.

Each weekly summary must include:• Name of Individual• Type of service provided• Week of service (must identify the calendar week of service – Sunday

through Saturday – and the year)• Place of service• Description of the activity(s) the individual participated in to address their

day habilitation outcomes• Name and title of service provider• Signature of service provider

Each daily log must include:• Date of service (month, day, year)• Begin and end time of service event – must include any times the

individual signed out to receive other services• Signature of the service provider for each day of attendance

To document Day Habilitation on a daily basis, program providers must ensure that acorresponding written narrative exists for each day billed documenting service delivery.

Each written narrative must include:• Name of individual• Type of service• Date of service (month, day, year)• Place of service• Exact begin and end time of each service event – must include any times

the individual signed out to receive other services• Description of the activity(s) the individual participated in to address their

day habilitation outcomes• Name and title of service provider• Signature of service provider per service event



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Supported Employment

Component Definition:Supported employment is employment in an integrated setting with on-goingindividualized support services. Employment is work for which a participant iscompensated by his or her employer in accordance with the Fair Labor Standards Act.Supported employment is provided in an integrated work setting (i.e., a job site wheregenerally no more than one employee or 3% of the employees have disabilities) unlessthe participant’s person-directed plan indicates otherwise or the employer subsequentlyhires an additional employee with disabilities who is receiving services from a providerother than the participant’s program provider or is not receiving services. The supportedemployment component includes services and supports, including supervision andtraining, essential to sustain paid work by a participant.

Supported Employment is provided away from the participant’s place of residence anddoes not include payment for the supervisory activities rendered as a normal part of thebusiness setting.

Supported Employment furnished under the waiver is not available under a programfunded by either the Rehabilitation Act of 1973 or P.L. 94-142. Documentation will bemaintained in the file of each participant receiving Supported Employment verifying thatsupported employment is not otherwise available to the participant under a programfunded under the Rehabilitation Act of 1973, or P.L. 94-142.

Supported Employment Billable Time/Activities:

• Training, supports, or interventions related to sustaining the individual's employmentprovided directly to the individual on-the-job by program provider staff orcontractors.

• Face-to-face or telephone contacts with the individual’s supervisor(s) or on behalf ofa specific individual by the supported employment provider necessary to sustain theindividual's employment.

• Participating in service planning team meetings.

• Supported Employment provided by an individual’s program provider, who is alsothe individual’s community employer, when a variance is approved by TDMHMR.The department may approve a variance for a period of time not to exceed one year ifat the time of the individual’s enrollment into the TxHmL program the individual isreceiving general revenue funded Supported Employment from the program provider.



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Supported Employment Non-billable Time/Activities:

• Activities conducted prior to the individual's employment such as employmentinterest assessments or interviews conducted with the individual.

• Community job development activities such as job searches or completing jobapplications.

• Supported Employment services provided by someone other than programprovider staff or contractors.

• Activities provided to an individual who is eligible for supported employmentthrough the public school system, the Texas Rehabilitation Commission, or theTexas Commission for the Blind.

• Activities provided to an individual when the individual is not on the job.

• Staff time spent providing transportation to an individual between the individual'shome and the supported employment/day habilitation site.


Supported Employment Documentation Requirements:

A written narrative for each service event that describes the service delivered andincludes information pertaining to the individual’s progress toward goals and objectives.

The written narrative must include:

• Name of individual• Type of service• Date of service (month, day, year)• Place of service• Actual begin and end time of service event• Detailed description of the service event• Name and title of service provider• Signature of service provider

Documentation that supported employment services are unavailable to the individualthrough the state rehabilitation agency (e.g., Texas Rehabilitation Commission) or stateeducation agency (e.g., the public school system) must be kept in the individual record.



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Respite


Provided for the planned or emergency short-term relief of the unpaid caregiver of aparticipant. This component provides a participant with personal assistance with activitiesof daily living (grooming, eating, bathing, dressing, and personal hygiene) and functionalliving tasks; assistance with planning and preparing meals; transportation or assistance insecuring transportation; assistance with ambulation and mobility; reinforcement ofbehavioral support of specialized therapies activities; assistance with medications and theperformance of tasks delegated by a Registered Nurse in accordance with state law; andsupervision of the participant’s safety and security. This component includes habilitationactivities that facilitate the participant’s inclusion in community activities, use of naturalsupports and typical community services available to all people, social interaction andparticipation in leisure activities, and development of socially valued behaviors and dailyliving and functional living skills.

Out-of-Home Respite

When respite is provided out-of-home (in a setting other than the recipient's residence),reimbursement will be available for each 15-minute unit of service for up to 10 hours ofservice (40 units). When the out-of-home respite interval spans a time period greater than10 hours in a calendar day, reimbursement is available as a daily unit only. An individualreceiving out-of-home respite for 10 or more hours is not eligible to receive CommunitySupport on the same calendar day. Respite Care provided in a setting other than theindividual's residence includes the provision of room and board.

In-Home Respite

When respite is provided in the individual's home, reimbursement is paid for each 15minutes of service and may be billed up to 96 units in a calendar day.

Respite Billable Activities:

• Face-to-face contact with the individual to provide respite care

• Providing transportation to and from day habilitation activities and transportationto facilitate the individual’s participation in community activities and use oftypical community services



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Respite Non-Billable Activities:

• Respite Care provided to individuals who live independently.

• Hourly respite may not be billed for the same time period Day Habilitation,Community Support, or Supported Employment is billed.

• Hourly or daily respite may not be billed for the same time period CommunitySupport is billed.

Unit of Service for Out-of-Home respite:15 minutes (up to 40 units) or daily (41 or more 15-minute units provided in onecalendar day)

Unit of Service for In-Home respite:15 minutes (up to 96 units in one calendar day)

Respite Documentation Requirements:

A written narrative for each service event that describes the respite service and whenappropriate includes information pertaining to the individual’s progress toward goals andoutcomes.

The written narrative must include:• Name of individual• Type of service• Place of service• Date of service (month, day, year)• Begin and end time of service event• Detailed description of the service provided• Name and title of service provider• Signature of service provider



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Dental TreatmentComponent Definition:Dental treatment is provided by dentist licensed by the Texas State Board of DentalExaminers. The cost of dental treatment will be included in assessing the cost-effectiveness of waiver services. The total amount allowable for the dental treatmentcomponent is limited to a maximum expenditure of $1,000 per participant per IndividualPlan of Care year. Elements of this component include the following:

A. Emergency dental treatment. Those procedures necessary to control bleeding,relieve pain, and eliminate acute infection; operative procedures that arerequired to prevent the imminent loss of teeth; and treatment of injuries to theteeth or supporting structures.

B. Preventive dental treatment. Examinations, oral prophylaxes, and topicalfluoride applications.

C. Therapeutic dental treatment. Treatment that includes, but is not limited to,pulp therapy for permanent and primary teeth; restoration of cariouspermanent and primary teeth; maintenance of space; and limited provision ofremovable prostheses when masticatory function is impaired, when anexisting prosthesis is unserviceable, or when aesthetic considerations interferewith employment or socially development.

D. Orthodontic dental treatment. Procedures that include treatment of retaineddeciduous teeth; crossbite therapy; facial accidents involving severe traumaticdeviations; cleft palates with gross malocclusion that will benefit from earlytreatment; and severe, handicapping malocclusions affecting permanentdentition with a minimum score of 26 as measured on the HandicappingLabio-lingual Deviation Index.

Cosmetic orthodontia is excluded from the Dental Treatment component.

Dental Treatment is provided under this waiver when no other financial resource for suchtreatment is available or when other available resources have been exhausted.Participants who are under 21 years of age must first exhaust dental treatment benefitsthrough the Texas Health Steps – Comprehensive Care Program before dental treatmentmay be provided under this waiver.



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Dental Treatment Covered Under Service Component

• Dental treatment necessary to control bleeding, relieve pain and eliminate acuteinfection

• Operative procedures that are required to prevent the imminent loss of teeth

• Treatment of injuries to the teeth or supporting structures

• Dental examination, oral prophylaxes and topical fluoride applications

• Pulp therapy for permanent and primary teeth

• Restoration of carious permanent and primary teeth

• Maintenance of space

• Limited provision of removable prostheses (e.g., dentures) when masticatoryfunction is impaired, when an existing prosthesis is unserviceable, or whenaesthetic considerations interfere with employment or social development

• Treatment of retained deciduous teeth

• Crossbite therapy

• Treatment of facial accidents involving severe traumatic deviations

• Treatment of cleft palates with gross malocclusion that will benefit from early treatment

• Treatment of severe, handicapping malocclusions affecting permanent dentitionwith a minimum score of 26 as measured on the Handicapping Labio-lingualDeviation Index



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Dental Non-Billable Time/Activities:

• Cosmetic orthodontia

• Dental treatment provided to children who are eligible for dental services throughthe Texas Health Steps Program

Unit of Service: Actual cost of treatment up to $1,000 per IPC year per individual

Billable Service Units: Billing should occur as eligible dental treatment is delivered

Documentation: Use form 4116A and instructions for billing for dental treatment. If theindividual is under the age of 22, documentation must be maintained that the item wasnot available through THSteps-CCP.

Additional Considerations:

• Service provider must meet minimum provider qualifications

• Provider maintains an agreement with licensed dentist



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Adaptive Aids


Adaptive aids are devices, controls, or appliances that are necessary to address specificneeds identified in an individual’s Individual Plan of Care (IPC). Adaptive aids enableindividuals to increase their abilities to perform activities of daily living, or to perceive,control, or communicate within the environment in which they live. Adaptive aidsinclude items that assist an individual with mobility and communication, and ancillarysupplies and equipment necessary for the proper functioning of such items. Also includedare medically necessary supplies and items required for life support. Items reimbursedwith waiver funds shall be in addition to any medical equipment and supplies furnishedunder the Medicaid State plan. All adaptive aids must meet applicable standards ofmanufacture, design, and installation. An adaptive aid must be provided to a specificindividual and must be the exclusive property of that individual.

Reimbursement is not available for items and supplies that are not of direct medical orremedial benefit to the individual or items and supplies that are reimbursable through theMedicaid State Plan, other governmental programs (e.g., Medicare), or private insurance.

The maximum amount reimbursable for adaptive aids through the TxHmL program is$6,000 per individual per IPC year.

The individual's service planning team must recommend all adaptive aids. Furthermore,items costing more than $500.00 must be recommended by the service planning teambased on written evaluations and recommendations by the individual's physician, alicensed occupational or physical therapist, a psychologist, a licensed nurse, a licenseddietician or a licensed speech or language pathologist, who is qualified to assess theindividual's need for the specific adaptive aid. The written evaluation andrecommendation must very specifically document the necessity and appropriateness ofthe adaptive aid to meet the specific needs of the consumer.

GENERAL REQUIREMENTS

Providers will not be reimbursed for adaptive aids that are not included on the "List ofReimbursable Adaptive Aids." Furthermore, any item appearing on the List of Non-Reimbursable Adaptive Aids is specifically excluded. Please refer to the list of non-reimbursable Adaptive Aids that follows.

Service Coordinators are required to pursue alternate funding sources that the individualmay be eligible for before submitting a request for approval for purchase or lease of anadaptive aid to the Texas Department of Mental health and Mental Retardation(TDMHMR). When an item may be purchased or leased through the Medicaid State Plan



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or Medicare, it is the responsibility of the Service Coordinator, working with a DurableMedical Equipment (DME) supplier, to accurately submit claims and to exhaust theappeals process of these funding sources before payment is requested from the TxHmLProgram. Any information that is required by the alternate funding source must beprovided. For those individuals who are also eligible for

Medicare benefits, application must be made to Medicare before applying for MedicaidState Plan benefits (e.g., Medicaid Home Health or Texas Health Steps.) The TxHmLProgram will not reimburse a provider for adaptive aids denied by Medicare or MedicaidState Plan benefits due to any of the following reasons:

• information required to make payment was missing,• information required to make payment was insufficient,• information required to make payment was incorrect, or• equipment is covered only if rented.

If the purchase or lease of an item is denied by Medicaid or Medicare due to a “lack ofmedical necessity,” the Service Coordinator must appeal the denial to Medicaid orMedicare. TDMHMR will not consider reimbursement for items denied due to a “lack ofmedical necessity” without reviewing a copy of the written appeal and the writtenresponse from Medicare or Medicaid (Denial of Benefits Letter). After reviewing theDenial of Benefits letter, TDMHMR will make a determination to approve or deny therequest. To avoid delays in service provision, Service Coordinators should be familiarwith the process for obtaining adaptive aids or durable medical equipment (DME)through the Medicaid State Plan and Medicare and with the process for appealing denialsby these programs.

The “List of Reimburseable Adaptive Aids” identifies items that are typically coveredthrough Medicaid Home Health or Texas Health Steps. Items on the list marked with a(1) or (2) must be submitted by a DME supplier to the State Medicaid Plan beforesubmission to TDMHMR. Any item identified with a (1) or (2) that is submitted directlyto TDMHMR for reimbursement or prior approval and does not include a denial letterfrom the appropriate Medicaid State Plan program, will be denied by TDMHMRregardless of cost.

Items marked with (1) are typically available through Medicaid Home Health.Items marked with (2) are typically available through Texas Health Steps.

Items appearing on the “List of Reimbursable Adaptive Aids” not marked with a (1) or(2) are not typically covered by Medicaid or Medicare and may be submitted toTDMHMR for payment.



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In general, providers are required to have three bids included with any request forreimbursement of an adaptive aid or prior approval. Providers may not be required tosubmit three bids if the adaptive aid is purchased through a Durable Medical Equipment(DME) supplier enrolled as a Durable Medical Equipment Home Health provider(DMEH) and certified by Medicare. TxHmL Program providers should choose a DMEsupplier based on comparison of prices, delivery time, quality of services, loanerequipment availability during repairs, repair history, and warranties. In addition, TxHmLProgram providers may not be required to submit three bids due to the uniquespecifications or limited availability of the aid or the distance of the individual fromDME suppliers. Justification and agreement by the service planning team for notproviding three bids must be included with a request for prior approval. TDMHMR willdetermine whether three bids are required and notify the provider of its determination.

TDMHMR will approve the lowest bid submitted unless the program provider submitsand TDMHMR accepts written justification for a higher bid. Individual or familypreference for a specific supplier is not sufficient justification for approval of a higherbid. For adaptive aids that cost less than $500, and are not recommended for priorapproval (no designation of “P”), TxHmL providers are required to maintain writtendocumentation that identifies the need for the adaptive aid and authorization from theservice planning team. This supporting documentation may include written assessments,staffing summaries, medical history, evaluations, etc. This documentation must bemaintained by TxHmL providers and may be reviewed during billing and paymentreviews.

The Service Coordinator must:• Recommend the adaptive aid and determine whether a request for the adaptive aid

should be submitted to an alternate funding source for payment;• Submit the request to the alternate funding source in accordance with MRA Program

Principles for Mental Retardation Authorities;• Provide the TxHmL Program provider with a copy of the written denial from an

alternate funding source, commonly referred to as a Denial of Benefits letter, and;• Ensure the IPC includes the cost of the adaptive aid and that the PDP includes

appropriate justification for the purchase of the AA when an alternate funding sourcedoes not exist to cover the cost of the item.

The Program Provider must:• Assist by transporting the individual to appropriate appointments when assessments

are required;• Secure the necessary bids for the adaptive aid;• Prepare and submit the packet (including any denials obtained by the Service

Coordinator from alternate funding sources) to TDMHMR for items recommendedfor prior approval, and;

• Submit the necessary documentation to TDMHMR for authorization of payment in atimely manner.



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PRIOR APPROVAL PROCESS

The purpose of the prior approval process is to help ensure TxHmL Program providersdo not purchase adaptive aids that will not be reimbursed by TDMHMR. Programproviders are strongly encouraged to request prior approval from TDMHMR beforepurchasing an adaptive aid in any of the following categories:

• An adaptive aid costing more than $500, or;• an adaptive aid marked with a “(P)” on the “List of Reimbursable Adaptive

Aids.”

Prior approval requests must include copies of written denials, (e.g., Denial of BenefitsLetter) and the results of any appeals from alternate funding sources. In addition to thealternate funding sources identified on the “List of Reimbursable Adaptive Aids”, otherresources of funding are identified in the section of this packet entitled “AlternateFunding Sources.”

To request prior approval for an adaptive aid, a program provider must make a request toTDMHMR prior to purchase of the adaptive aid. One request for prior approval may besubmitted for multiple items on the List of Reimbursable Adaptive Aids if the items arewithin the same category, (e.g., Mobility Aids, Lifts, etc.) Separate requests for priorapproval and an accompanying packet that includes items 1-5 below must be submittedfor items in different categories. For example, a van lift (101) may not be submitted witha request for an electric wheelchair (157), because they are in different categories.However, a request for approval of an electric wheelchair could be submitted with arequest for approval of a portable wheelchair ramp and a travel seat, as they are all in thecategory of Mobility Aids.

An “AA/MHM Request for Prior Approval Form” (see Appendix B) must be completedby the program provider and submitted with each prior approval request.

Prior Approval will expire one year from the date of the TDMHMR Prior Approval.



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The following items must be submitted before a prior approval request will beconsidered by TDMHMR:

1. For items that cost more than $500.00, a legible copy of the recommendation(s)and the assessment(s) or evaluation(s) by the professional qualified to assess theindividual’s need for the specific adaptive aid clearly describing how theadaptive aid will assist the individual in community living. To find a completelisting of which medical professionals may recommend a specific adaptive aid,please refer to the notations beside the specific adaptive aids listed on the “Listof Reimbursable Adaptive Aids,” (pg. 45-48). The assessment must have beencompleted no more than twelve months prior to submission to TDMHMR.

2. A detailed description of the adaptive aid. Documentation may include pictures,brochures, and other descriptive information, and;

3. A copy of the proceedings from the service planning meeting and signaturesheet, including any discussions concerning the assessment(s) andrecommendation(s) and any additional information used in recommending theadaptive aid. The Service Coordinator, and consumer and/or LAR mustparticipate in the meeting and sign the signature sheet.

4. Copies of itemized bids from three suppliers of adaptive aids or documentationjustifying the provider’s request for an exception from this requirement asdescribed in the “General Requirements.” A bid must itemize the variouscomponents of the adaptive aid, if applicable, each components cost, and includethe name, address and telephone of the vendor.

5. Copies of written denials and results of appeals (e.g., Denial of Benefits Letter)for the specific adaptive aid from potential alternate funding sources, reflectingthat a timely and complete request was made and any additional requestedinformation was provided.

6. An “AA/MHM Request for Prior Approval Form” (see Appendix B) must becompleted by the program provider and submitted with each prior approvalrequest.



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AUTHORIZATION OF PAYMENT WITHOUT COMPLETING THE PRIORAPPROVAL PROCESS

If the items listed in 1-5 above have been completed prior to purchase of the adaptive aidand are included with the request for authorization of payment, TDMHMR may approveauthorization of payment for the adaptive aid, even if prior approval was not obtained.Any request for authorization of payment for an adaptive aid that did not receive priorapproval and is subsequently denied by TDMHMR will be returned to the provider.

TDMHMR PROCESS FOR PRIOR APPROVAL

Requests for prior approval will be assigned a Prior Approval Tracking Number.TDMHMR will acknowledge receipt of the request for prior approval on CARE ScreenC75: Prior Approval Inquiry Request Screen. TDMHMR will assign a prior approvalstatus to each request in CARE screen C75 (within two weeks) of receipt. The programprovider will have to monitor C75 for status of prior approval and any requests foradditional information. A complete new packet must be submitted for furtherconsideration if the requested information is not received by TDMHMR within thirtydays.

If an emergency arises and items are required immediately, i.e., person had an accidentor is unexpectedly coming out of the hospital etc., the program provider should contactone of the TDMHMR staff persons listed below to expedite the approval process.

Requests for prior approval of an adaptive aid may be faxed to 512-206-5725, AttentionAdaptive Aids/Minor Home Modifications Committee. Requests may also be mailed tothe following address:

Adaptive Aids/Minor Home Modifications CommitteeMedicaid AdministrationTDMHMRP. O, Box 12668Austin, TX. 78711-2668

Questions concerning specific adaptive aids may be addressed to the following staffpersons:

Roberta Thomas (512) 206-5676Elaine Howe (512) 206-5819

John Meza (512) 206-5035 Sean Ivie (512) 206-4746 Laticia Shelton (512) 206-5506



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TDMHMR PROCESS FOR REIMBURSEMENT

TxHmL Program providers are responsible for submitting all requests forauthorization of payment directly to TDMHMR (form4116A form and receipts).TxHmL Program providers who do not receive prior approval for adaptive aidsmust submit all of the required documentation listed in items 1-5 of the “PriorApproval Process” with their request for authorization of payment.

The request for authorization of payment must be submitted to TDMHMR within 95calendar days after the end of the month in which the adaptive aid was provided. Theonly exception to the claims submission deadline is when the Service Coordinator hassubmitted a request for reimbursement to an alternate funding source. Program providershave 95 days from the end of the month in which the alternate funding source disposed ofthe claim to request authorization of payment from TDMHMR. A request forauthorization of payment to TDMHMR that fails to meet the filing deadline will bedenied. The request for authorization of payment must include the 4116A Form andappropriate receipts before TDMHMR will approve payment. If any of the requiredinformation is not included with the request for authorization of payment TDMHMRcannot approve authorization. A program provider must resubmit a complete packet forTDMHMR’s consideration of the corrected request for payment. A corrected request forauthorization of payment must be received by TDMHMR within180 days after the end ofthe month in which the adaptive aid was provided or within 45 days after the date ofnotification of the rejected request for authorization, whichever is later.

Requests for authorization of payment to TDMHMR for items that are identified with (1)or (2) on the “List of Reimbursable Adaptive Aids” but are not recommended for priorapproval, (i.e., cost less than $500.00 and/or not designated with a (P), must beaccompanied by a Medicare and/or Medicaid written denial before payment will bemade. Without the written denial these items will be rejected for payment.



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LIST OF REIMBURSABLE ADAPTIVE AIDSThe following items, including repair and maintenance of such items not covered bywarranty, are reimbursable adaptive aids. Adaptive aids that cost more than $500.00 mustbe recommended by the professional most qualified to assess the individual’s need for thespecific adaptive aid. A list of qualified staff persons and abbreviations can be found onpage 49:

Lifts

101 Vehicle lift adaptations for a vehicle owned by an individual, an individual’sfamily member, or foster companion care provider if it is the primary mode oftransportation for the individual (available only at 5-year intervals and proof ofownership by the individual, family member, or foster/companion care providermust be submitted). *Repair and maintenance cost that exceeds the warrantydoes not have to meet the 5-year interval requirement. (P) (OT/PT) (MD)

104 Hydraulic, manual or electronic lifts (1) (2) (OT/PT) (MD)128 Transfer benches (1) (2) (OT/PT) (MD)

Mobility Aids

106 Crutches, walkers, canes (1) (2) (OT/PT) (MD)107 Orthotic devices, orthopedic shoes and braces (2) (OT/PT) (MD)157 Manual or electric wheelchairs and necessary accessories (1) (2) (OT/PT) (MD)158 Forearm platform attachments for walkers and motorized wheelchairs (1)(2)

(OT/PT) (MD)159 Portable/modular wheelchair ramps (1) (2) (OT/PT) (MD)160 Batteries and chargers for mobility aids (1) (2) (OT/PT) (MD) (RN/LVN)161 Gait trainers, gait belts (1) (2) (OT/PT) (MD) (RN/LVN)163 Strollers, pushchairs, travel seats (2) (OT/PT) (MD)

Positioning Devices

151 Hospital beds (1) cribs (2) (OT/PT) (MD)154 Standing boards/frames, positioning chairs, wedges (1) (2) (OT/PT) (MD)155 Trapeze bars (1) (2) (OT/PT) (MD)156 Lift chair to assist in standing or sitting (lift mechanism is an item reimbursable

through Medicaid) (P), replacement slings (for barrier free lifts only) (OT/PT) (MD)162 Bath/shower chairs (1) (2) (OT/PT) (MD) (RN/LVN)164 Potty/commode chairs (1) (2) (OT/PT) (MD) (RN/LVN)165 Bathtub rails (1) (2) (OT/PT) (MD)(P) Prior approval recommended(1) Available through Medicaid Home Health(2) Available through Texas Health Steps



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Control switches/pneumatic switches and devices

109 Sip and puff controls (1) (2) (OT/PT)110 Adaptive switches (OT/PT)

Environmental control units

111 Adapted locks (P) (OT/PT)112 Electronic control units (P) (OT/PT)114 Voice activated, light activated, and motion activated devices (P) (OT/PT)

Medically necessary supplies

120 Diapers(1) (2), diaper wipes(1) (2), and ** disposable gloves** (MD) (RN/LVN)121 Nutritional supplements such as Ensure wafers, powder mix, liquid or Multi-

vitamins for individuals with medical condition requiring a nutritionalsupplement* (2) (MD)

122 Enteral feeding formulas and supplies (1) (2) (MD)201 Medically necessary supplies for tracheotomy care, decubitus care, ostomy care,

respirator/ventilator care, or catheterization (P) (1) (2) (MD)206 Glucose monitors (MD) Supplies for individual’s use in self-monitoring (1) (2)

(MD) (RN/LVN)207 Adapted medication dispensers, pill crushers (MD) (RN/LVN)208 Air humidifiers, purifiers and specialized air filters (P) (MD)209 Muscle stimulators (P) (OT/PT) (MD)210 Temporary lease or rental of medically necessary durable medical equipment to

allow for equipment repair, purchase or replacement (1) (2) (P) (OT/PT) (MD)(RN/LVN)

* Claims for nutritional supplements must include a completed and signed Home Health(Title XIX) DME/Medical Supplies Physician Order Form and a written statement from theCase Manager that the individual does not meet the Medicaid Home Health eligibilityrequirements (over 21, not on G-tube and not sole source of nutrition). Only nutritionalsupplements listed in the Texas Medicaid Provider Procedures Manual will be reimbursed.

** Disposable gloves do not need prior approval

(P) Prior approval recommended(1) Available through Medicaid Home Health(2) Available through Texas Health Steps



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Medically necessary supplies (continued)

211 Urinals (1) (2) (MD) (RN/LVN)212 Specialized fever thermometers (MD) (RN/LVN)213 Specialized scales (P) (MD) (RN/LVN) (DI)214 Medical support hose (MD) (RN/LVN)215 Specialized clothing/ dressing aids (P) Bibs (OT/PT) (MD) (RN/LVN)216 Specialized or treated mattresses/covers (2) (P) (MD) (RN/LVN)217 Egg-crate, sheepskin and other medically necessary mattress pads and covers (1)

(2) (P) (MD) (RN/LVN)218 Cleft Plate feeder (1) (2) (MD) (OT/PT) (DI)219 Blood pressure and pulse monitor for individual’s use in self-monitoring (1) (2) (MD) (RN/LVN)220 Eyeglasses (2) (OPH) (OPT)

Communication aids (including batteries)

124 Direct selection, alphanumeric, scanning and/or encoding communicators (2) (P)(SP)

125 Speech amplifiers, and augmentative devices (1) (2) (P) (SP)126 Interpreter service (not for routine daily communication) (P) (SP) (AU) (MD)127 Repair and maintenance of communication aids (1) (2) (SP)251 Emergency response systems/service (P), Medical Alert Bracelets (MD)

(RN/LVN)254 Communication boards or books (2) (SP)255 Closed-captioning devices for persons with hearing impairments (AU)256 Signature stamps for persons with visual impairment (OPH) (OPT)257 Signature guides for persons with visual impairment (OPH) (OT/PT)258 Personal computers & accessories to augment receptive & expressive

communication (P) (SP)259 Specialized training for augmentative communication programs, not to exceed

$1000.00 per IPC year (2) (P) (SP)260 Hearing aids (2) (A) Batteries ( 2) (AU) (MD) (RN/LVN)




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Adapted/modified equipment for activities of daily living

401 Reachers (OT/PT)402 Stabilizing devices, such as Dycem mats (OT/PT) (MD)403 Holders (OT/PT)404 Adapted/modified dinnerware, eating/drinking utensils, meal preparation devices

(OT/PT)405 Specialized clocks/wristwatches for persons with visual or hearing impairments

(OT/PT)406 Electric razors or electric toothbrushes for persons with muscular weakness or

limited range of motion (OT/PT)407 Speaker telephones, “large button” or Braille telephones for use by persons who

are verbal but cannot use a conventional telephone (OT/PT)408 Microwave ovens if use of a conventional oven presents a safety hazard (P)

(OT/PT)409 Adaptive bathing tools, (e.g., hand held shower devices) (1) (2) (OT/PT)

Safety restraints and safety devices

113 Safety restraints (2) (PS) (BA) (MD) Wheelchair tie downs (OT/PT) (MD)(RN/LVN)

450 Bed rails (1) (2) (OT/PT) (MD) (RN/LVN)451 Safety padding (1) (2) (PS) (BA) (OT/PT) (MD)452 Helmets (due to seizure disorder or other medical condition) (1) (2) (PS) (BA)

(MD) (RN/LVN)453 Adaptations to furniture (P) (PS) (BA) (OT/PT)

Medications

Medications prescribed by a physician are approved and provided through theTexas Department of Health (TDH) Vendor Drug Program




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Abbreviations: Medical Professional

• AU - Audiologist• BA - Behavior Analyst• DI - Dietitian• LVN - Licensed Vocational Nurse• MD - Medical Doctor• OT - Occupational Therapist• OPH - Ophthalmologist• OPT - Optometrist• PT - Physical Therapist• PS - Psychologist• RN - Registered Nurse• SP - Speech Pathologist



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NON-REIMBURSABLE ADAPTIVE AIDS

• Appliances (washer, dryer, stove, dishwasher, vacuumcleaner, etc.)

• Swimming pool, hot tub.• Eye exams• Athletic and tennis shoes• Automobiles• Lift adaptations attached to vehicle other than the

individual's, the individual’s family or foster/companioncare provider

• Adaptive toys• Recreation equipment (swing set, slides, etc.)• Personal computers and software for teaching purposes• Daily hygiene products (deodorant, lotions, soap,

toothbrush, toothpaste, feminine products, band-aids, q-tips,etc.)

• Rent subsidy• Food• Bedding supplies (bed covers, pillows, sheets, etc.)• Exercise equipment• Taxi fares• Intra and Interstate transportation services• Bus Passes• Pagers, including monthly service• Telephones, including Mobile Phones and monthly service• Home Security Systems, including monthly service



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Minor Home Modifications


Minor Home Modifications are physical adaptations to a home that are required toaddress specific needs identified in the individual's Individual Plan of Care (IPC). Minorhome modifications are necessary to ensure the health, welfare, and safety of theindividual, or to enable the individual to function with greater independence in the home.Without the modification, the individual would require institutionalization. Modificationsinclude the installation of ramps and grab bars, widening of doorways, specializedaccessibility adaptations, kitchen and bathroom modifications and safety adaptationsnecessary for the welfare of the consumer. All modifications/adaptations shall beprovided in accordance with applicable state or local building codes to existingstructures.

Excluded are adaptations or improvements that are of general utility and are not of directmedical or remedial benefit to the individual. Examples of excluded modifications areinstallation of carpeting, roof repair, central air conditioning, major home renovations,and construction of additional rooms or other modifications that add to the total squarefootage of a home.

The individual’s service planning team must recommend all minor home modifications.Any modification (s) costing more than $1,000 must be recommended by the serviceplanning team based on prior written evaluations and recommendations from a physician,a licensed occupational or physical therapist, or a licensed psychologist who is qualifiedto assess the individual's need for the specific minor home modification. The writtenevaluation must document the necessity and appropriateness of the minor homemodification to meet the specific needs of the individual.

The total amount allowable for the minor home modification in the TxHmL Program is alifetime maximum expenditure of $7500. Once that maximum is reached, $300 per IPCyear is allowed for repair or replacement of a modification or for additionalmodifications.



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GENERAL REQUIREMENTS

TxHmL Program providers must contract directly with the minor home modificationservice provider. Under no circumstances should the individual or individual’s familymember contract with the minor home modification service provider. Reimbursement byTDMHMR is paid directly to the TxHmL Program provider. The TxHmL Programprovider is responsible for inspecting the home modifications to determine if the workhas been completed and the needs of the individual have been met.

TxHmL Program providers will not be authorized for payment for minor homemodifications that are not included on the “List of Reimbursable Minor HomeModifications.” Furthermore, any item appearing on the “List of Non-ReimbursableMinor Home Modifications” is specifically excluded.

In general, program providers are required to have three bids included with any requestfor authorization of payment of a minor home modification or prior approval. Programproviders may not be required to submit three bids if the minor home modification isavailable from only one supplier due to the distance of the individual from other minorhome modification providers. Justification and agreement by the service planning teamfor not providing three bids must be included with any request for prior approval made bythe TxHmL Program provider. TDMHMR will determine whether three bids are requiredand notify the provider of its determination.

TDMHMR will approve the lowest bid unless the program provider submits andTDMHMR accepts written justification for a higher bid. Individual or family preferencefor a specific supplier is not sufficient justification for approval of a higher bid.

For minor home modifications that cost less than $1,000, TxHmL Program providers arerequired to maintain written documentation that identifies the need for the minor homemodification and TxHmL service planning tam recommendation. This supportivedocumentation may include written assessments, service planning team summaries,medical history, evaluations, etc. This documentation must be maintained by the TxHmLProgram providers and may be reviewed during billing and payment reviews.



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The Service Coordinator must:

• recommend the minor home modification;• ensure the individual’s IPC includes the cost of the minor home modification.

The TxHmL provider must:

• Assist with coordinating and transporting the individual for assessments, andgathering all information necessary to complete the prior approval request packet;

• Secures the necessary bids and contracts directly with the selected vendor;• Ensures the work is completed in a manner satisfactory to the individual and

individual’s family;• Submit the necessary documentation to TDMHMR for authorization of payment in a

timely manner, and;• Prepare and submit the packet to TDMHMR for items recommended for prior

approval.

The program provider should contact TDMHMR prior to recommending any minor homemodification for an individual enrolling from a State School, as minor homemodifications cannot be reimbursed if provided prior to the individual’s enrollment intothe TxHmL program.

PRIOR APPROVAL PROCESS

The purpose of the prior approval process is to help ensure TxHmL providers do notpurchase minor home modifications that will not be reimbursed by TDMHMR. Programproviders are strongly encouraged to request prior approval from TDMHMR before theprovider purchases a minor home modification in any of the following categories:

• A modification that costs more than $1,000, or;• a minor home modification marked with a “(P)” on the “List of Reimbursable

Minor Home Modifications.”

To request prior approval, the program provider must make a request to TDMHMR priorto the purchase of the minor home modification. An “AA/MHM Request for PriorApproval Form” (see Appendix B) should be completed by the Service Coordinator andsubmitted with each prior approval request to avoid delays in processing.

The TDMHMR Prior Approval expires one year from the date of the approval.



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The following items must be submitted before a request will be considered:

1) For items that cost more than $1,000.00, a legible copy of the recommendation(s)and the assessment(s) or evaluation(s) by the professional most qualified to assessthe individual's need for the specific minor home modification clearly describinghow the minor home modification will assist the individual in the community. Withthe exception of medically necessary heating and cooling adaptations, all minorhome modifications require an on-site inspection of the individuals home in additionto the assessment of the individual by the most qualified professional. Theassessment must have been completed no more than twelve months prior tosubmission of the request for prior approval to TDMHMR.

2) A detailed description of the minor home modification. Supportingdocumentation may include drawings with dimensions of the proposed minor homemodification. The drawings should portray the existing floor plan and the proposedfloor plan.

3) A copy of the service planning meeting recommendations and signature sheet,including any discussions concerning the assessment(s) and recommendation(s) andany additional information used in recommending the minor home modification.The Service Coordinator and consumer or LAR must participate in the meeting andsign the signature sheet.

4) Copies of itemized bids from three suppliers of minor home modification ordocumentation justifying the program provider’s exemption from this requirementas described in the “General Requirements.” A bid must include the following:

a) Name, address, and telephone number of the vendor;

b) detailed line item description of each item as reflected onthe list of reimbursable minor home modifications and eachtask to be performed by the vendor with itemized costs and;

c) the total cost of the minor home modification.

5) An “AA/MHM Request for Prior Approval Form” (see Appendix B) should becompleted by the Service Coordinator and submitted with each prior approvalrequest to avoid delays in processing.



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AUTHORIZATION OF PAYMENT WITHOUT COMPLETING THE PRIORAPPROVAL PROCESS

If the items listed in 1-4 above have been completed prior to purchase of the minor homemodification and are included with the request for authorization of payment, TDMHMRmay approve authorization of payment for the minor home modification, even if priorapproval was not obtained. Any request for authorization of payment for a minor homemodification that did not receive prior approval and is subsequently denied by TDMHMRwill be returned to the provider.

TDMHMR PROCESS FOR PRIOR APPROVAL

Requests for prior approval will be assigned a Prior Approval Tracking Number.TDMHMR will acknowledge receipt of the request for prior approval on Care ScreenC75: Prior Approval Inquiry Request Screen. TDMHMR will assign a prior approvalstatus to each request in C75 (within two weeks) of receipt of the request. The programprovider will have to monitor C75 for status of prior approval and any request foradditional information. A complete new packet must be submitted for furtherconsideration if the requested information is not received by TDMHMR within thirtydays.

Requests for prior approval for minor home modifications may be faxed to 512-206-5725, Attention Adaptive Aids/Minor Home Modifications Committee. Requests mayalso be mailed to the following address:

Adaptive Aids/Minor Home Modifications CommitteeMedicaid AdministrationTDMHMRP. O, Box 12668Austin, TX 78711-2668

Questions concerning specific minor home modifications may be addressed to thefollowing staff:

Elaine Howe (512) 206-5819Sean Ivie (512) 206-4746

Wende Young (512) 206-5096Laticia Shelton (512) 206-5506Roberta Thomas (512) 206-5676



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TDMHMR PROCESS FOR AUTHORIZATION OF PAYMENT

If prior approval was requested, the TxHmL Program provider must submit the priorapproval tracking number with their request for authorization of payment. TxHmLProgram providers who do not receive prior approval for a minor home modificationmust submit all of the required documentation listed in items 1-4 of the “Prior ApprovalProcess” with their request for authorization of payment.

The request for authorization of payment must be submitted within 95 calendar days afterthe end of the month in which the minor home modification was provided. The requestfor authorization of payment must include the 4116A Form with the prior approvaltracking number, and appropriate receipts before TDMHMR will approve payment. Ifany of the required information is not included with the request for authorization ofpayment TDMHMR cannot approve the request and will deny payment. A programprovider must resubmit a complete packet for TDMHMR’s consideration of the correctedrequest for authorization of payment. A corrected claim must be received by TDMHMRwithin 180 days after the end of the month the minor home modification was provided orwithin 45 days after the date of notification of the rejected request for authorization ofpayment, whichever is later.



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LIST OF REIMBURSABLE MINOR HOME MODIFICATIONS

The following items, including the repair and maintenance of such items, arereimbursable minor home modifications. Items that cost more than $1000.00 must berecommended by the professional most qualified to assess the individual’s need for thespecific minor Home modification. A list of qualified staff persons and abbreviationsfollow:

Purchase or repair of wheelchair ramps

301 Construction or repair of wheelchair ramps and/or landings to A.D.A.specifications (OT/PT)

Modifications to bathroom facilities

302 Roll-in showers (P) (OT/PT)303 Sink adaptations (OT/PT)304 Bathtub adaptations (P) (OT/PT)305 Toilet adaptations (OT/PT)306 Water faucet controls (OT/PT)307 Floor urinal and bidet adaptations (OT/PT)308 Plumbing adaptations (OT/PT)309 Turnaround space adaptations (P) (OT/PT)

Modifications to kitchen facilities

310 Sink adaptations (OT/PT)311 Sink cut-outs (OT/PT)312 Turnaround space adaptations (P) (OT/PT)313 Water faucet controls (OT/PT)314 Plumbing adaptations (OT/PT)315 Worktable/work surface adjustments (P) (OT/PT)316 Cabinetry adjustments (P) (OT/PT)

(P) Prior approval recommended



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Specialized accessibility and safety adaptations

317 Door widening (OT/PT)318 Floor adaptations for health/safety (P) (OT/PT)319 Handrails or grab bars (permanently attached to the wall) (OT/PT)320 Automatic door openers, adapted wall switches/outlets, specialized doorbells and

door scopes (P) (OT/PT)321 Voice activated, light activated, motion activated, and electronic devices (P)

(OT/PT)322 Fire Alarm adaptations (to existing systems only) (P) (OT/PT)324 Medically necessary heating/cooling adaptations prescribed by a physician

utilized to manage symptoms of a seizure disorder, respiratory or cardiacconditions, or inability to regulate body temperature (P) (MD)

325 Lever door handles (OT/PT)326 Barrier Free Lifts (OT/PT)327 Safety glass/film adaptations and safety padding adaptations (P) (PS) (BA) (MD)

(P) Prior approval recommended



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NON-REIMBURSABLE MINOR HOME MODIFICATIONS

• General repairs (such as leaking roofs, rotten porches, termiterepair, floor leveling, etc.)

• Remodeling bathroom, bedroom, etc.

• Adding additional square footage to the home

• Septic tank and installation

• General plumbing and electric work

• Hot water heater and installation

• Central heat and cooling systems installation and repairs

• Heaters, installation and repair

• Fire sprinkler systems or fire alarm systems, installation and repair

• Purchase and installation of appliances (washer, dryer, stove,dishwasher, vacuum cleaner, etc.)

• Fences

• Carports

• Driveways

• Decks

• Hot Tubs



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ALTERNATE FUNDING SOURCESTDMHMR is required to ensure that all sources of payment for which an individual maybe eligible are pursued. Funding sources include Medicare, Medicaid State Plan Services,Texas Rehabilitation Commission, public schools, and private insurance. Thus, ServiceCoordinators must seek funding from third party sources before seeking payment fromTDMHMR. Claims submitted to TDMHMR must include evidence that a proper,complete, and timely request was made to the alternate funding source before the claimwas denied. The following sources may provide adaptive aids and medical supplies forindividuals served in the TxHmL program.

Medicaid State Plan ServicesThere are two Medicaid State Plan programs that provide services to individuals enrolledin the TxHmL program. Funding for adaptive aids may be available from one of thesetwo programs. The “List of Reimbursable Adaptive Aids” identifies services that aretypically available from Texas Health Steps or Medicaid Home Health programs.

Texas Health Steps is a Title XIX Medicaid program, administered by the Health andHuman Services Commission (HHSC) and Texas Medicaid Healthcare Partnership(TMHP), that provides health screening, diagnosis, and treatment for individuals under21 years of age. It is the Texas version of Early and Periodic Screening Diagnosis andTreatment (ESPDT). This program offers comprehensive statewide medical and dentalcare services before health problems become chronic or irreversible and emphasizes theearly detection and treatment of medical problems. The program provides comprehensiveassessments of children’s growth, development, and health status by using Medicaidfunding to provide the services. Texas Health Steps also provides various adaptive aidsand medically necessary supplies for children, including nutritional supplements andincontinence supplies. Eye exams, eyeglasses, hearing services, orthotic and prostheticsupplies, and speech language pathology services are also available. The ComprehensiveCare Program of Texas Health Steps provides any health care service that is medicallynecessary, appropriate, and is a federally allowable Medicaid service regardless of thelimitations of the Texas Medicaid Program. Dental, occupational therapy and physicaltherapy and other professional services and evaluations for children under 21 must not bebilled to TDMHMR if they are available through Texas Health Steps.

Refer to items marked with a (2) on the “List of Reimbursable Adaptive Aids” for thoseaids available from Texas Health Steps. A durable medical equipment (DME) suppliermust be enrolled with Medicaid Home Health to be reimbursed for supplies and DMEthrough Texas Health Steps. An efficient method of accessing Texas Health Steps is tocontact a medical supply company that is registered with Medicaid as a Durable MedicalEquipment -- Home Health (DMEH) vendor. HCS providers should establish workingrelationships with DMEH vendor companies and utilize these companies to access TexasHealth Steps for their consumers. For more information concerning Texas Health Stepscall 800-757-5691.



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Medicaid Home Health is also a Title XIX Medicaid program administered by theTexas Health and Human Services Commission and Texas Medicaid HealthcarePartnership (TMHP), provides skilled nursing services, home health aide services,physical and occupational therapy, medical supplies, and durable medical equipment(DME) to Medicaid eligible individuals. Professional services are available to ameliorateacute conditions or exacerbation of acute conditions. Medical supplies and DME areavailable for individuals meeting the “Homebound” definition. Homebound is defined as“a condition due to illness or injury that restricts a recipient’s ability to leave home, orwhich makes leaving the home taxing or requires considerable effort, or is medicallycontraindicated.” The homebound requirement can be met when an individualwould be homebound if not for the provision of medically necessary equipment ormedical supplies covered by the Home Health services. Additional requirements arefor the individual to be under the continuing care and medical supervision of a physicianwho has established a plan of care for the individual. The physician must see individualswithin 30 days before the start of home health services. A medical need for covered homehealth professional services, DME, or supplies must be documented in the individual’shome health plan of care. Prior authorization from NHIC for all home health professionalservices, DME, or supplies is mandatory. Services must meet the individual’s existingmedical needs and be safely provided in the individual’s home.

Refer to items marked with a (1) on the “List of Reimbursable Adaptive Aids” for thoseaids available from Medicaid Home Health. A DME supplier must be enrolled withMedicaid Home Health to be reimbursed for supplies and DME through Home Health.An efficient method of accessing Medicaid Home Health is to contact a medical supplycompany that is registered with Medicaid as a DMEH vendor. HCS providers shouldestablish working relationships with DMEH vendor companies and utilize thesecompanies to access Medicaid Home Health. For more information concerning MedicaidHome Health call 800-925-8957.

MedicareSome individuals enrolled in TxHmL may also qualify for Medicare benefits. For theseindividuals the Service Coordinator working with the DME supplier must submit claimsfor adaptive aids to Medicare first before submission to Medicaid Home Health or TexasHealth Steps. If denied by Medicare, the Explanation of Medicare Benefits (EOMB)letter must accompany the request to Medicaid Home Health or Texas Health Steps. Afterthese resources have been exhausted, a claim may be submitted to TDMHMR.TDMHMR will not pay for the portion of an Adaptive Aid that can be obtained usingMedicare funds, including items that can be leased.

The 20% co-payment required of the individual for services through Medicare is areimbursable expenditure from the Medicaid Home Health or Texas Health StepsProgram. If Medicaid denies payment of the 20% co-payment, TDMHMR may reimburseproviders for the 20% portion of the item not covered by Medicare.



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Medicare in Texas may be contacted by calling (800) 252-9240. A Medicare informationbooklet is available by calling the Medicare Hotline at (800) 633-4227.

Texas Rehabilitation Commission (TRC)

TRC provides Vocational Rehabilitation (VR) services that help people with disabilitiesto prepare for, locate and keep jobs. An individual may be found eligible for VR servicesdepending upon his or her individual needs. Individuals may be eligible for TRC servicesif she or he:

• lives in Texas,• has a physical and/or mental disability that affects the ability to work,• has the ability to find and maintain a job after receiving TRC services,

and• requires services to help find and maintain a job.

Medicaid eligibility does not preclude or assure acceptance into the VR program.Services that may be available to TDMHMR consumers from the TRC include, but arenot limited to:

• Purchase of Mobility Aids including Wheelchairs and Walkers• Supported Employment Services• Physical Therapy and Occupational Therapy Services,• Other Adaptive aids specific to employment needs.

There are additional services available, depending on where an individual resides. TRCmay be contacted by calling (800) 628-5115.

Private Insurance

An individual receiving Medicaid services is required to inform his or her Medicaideligibility worker of any third party responsible for providing health care coverage to theindividual. This includes the name and relationship of the insured, the name of thepolicyholder, the policy number, and the dates the coverage is in effect. An individualliving at home with family may be covered by private insurance. Case Managers arerequired to make a good faith effort to determine whether an individual has privateinsurance coverage. Private insurance coverage must be accessed before submittingrequests for payment to Medicaid State Plan Services, Medicare, or TDMHMR.



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Public School Systems

Individuals receiving Special Education services may be eligible for some adaptive aidsthrough their local education agency (LEA). All efforts to ensure that an individual’sneeds for adaptive aids are met by the Individual Education Plan (IEP) must be exhaustedbefore requests for adaptive aids are submitted to TDMHMR. Items identified on the“List of Reimbursable Adaptive Aids” that are educational in nature require a writtendenial from the LEA Admission Review and Dismissal (ARD) Committee beforesubmission to TDMHMR for reimbursement. Prior approval is recommended for theseitems.

Other Sources

Additional information regarding funding and assistance is available from theTexas Information and Referral Network on the Internet atwww.hhsc.state.tx.us/tirn/tirnhome.htm or in a book entitled Finding Help in Texas.The book may be obtained by contacting the Texas Information and ReferralNetwork at P.O. Box 13247, Austin, TX 78711 or calling 512-424-6520 or faxing512-424-6591.



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FAIR HEARINGSFair Hearings are offered to individuals enrolled in the TxHmL program when a coveredservice has been denied or when a covered service has been limited in the amount anindividual may receive. 42 CFR Subpart E relates to Fair Hearing for applicants andRecipients. A Fair Hearing is the mechanism for an individual to appeal the decision byTDMHMR to deny covered services. The following guidelines serve to clarify when FairHearings are offered to the waiver recipient and their families.

Items that do not appear on the List of Reimbursable Adaptive Aids or ReimbursableMinor Home Modifications in the TxHmL Billing Guidelines are not covered items andtherefore will not be reimbursed if requested by the Waiver provider. As these items arenot covered services, a Fair Hearing is not offered when these items are requested by theindividual, the individual’s family/guardian, or the TxHmL provider. Individuals andtheir family members have no opportunity to appeal a decision not to provide a FairHearing for non-covered services/items.

Items that appear on the List of Reimbursable Adaptive Aids or List of ReimbursableMinor Home Modifications may be appealed if a request for these covered services hasbeen denied or limited in amount. In these circumstances a Fair Hearing will be offeredby TDMHMR. When TDMHMR denies a request for covered services the individualand/or their family member/guardian will receive notification of their opportunity toappeal this decision by requesting a Fair Hearing.

There are instances where TDMHMR will request the TxHmL Program provider toprovide missing information or additional information to clarify and or justify whycertain items are requested. For example, if a request for an adaptive aid exceeds$500.00 an assessment by the appropriate professional licensed to provide the servicemust accompany the request. When the assessment is not included with the request,notification is sent to the TxHmL Program provider indicating additional information isrequired before a decision can be rendered. Additional information such as bids,summaries of service planning deliberations, item descriptions, additional justification ofitems, and written denials from alternate funding sources may also be requested. In theseinstances, TDMHMR does not deny the request, but requests additional informationbefore making a decision to approve or deny the item. When additional information isrequested by TDMHMR, the individual or family is not given an opportunity, for a FairHearing unless they refuse to provide the information.

When TDMHMR requests additional information and the individual/family refuse tosubmit the additional information, the TxHmL Program provider is obligated to notifyTDMHMR of the refusal to provide the information. If the individual/family memberalso choose to appeal TDMHMR’s request for additional information the TxHmLProgram provider must notify TDMHMR. In this instance, TDMHMR will offer theindividual an opportunity for a Fair Hearing by notifying the individual in writing andproviding a form to be completed to request the Fair Hearing.

Documents

Txhml Billing Guidelines