Texas Department of Aging and Disability
Services
Community Living Assistance and Support
Services Provider Manual
Revision: 14-2
Effective:
Section 2000
Case Management Agency (CMA)
2100 Case Management Responsibilities
Revision 11-1;
Case management services are provided to all individuals receiving services in the Community
Living Assistance and Support Services (CLASS) program. Individuals must select a CMA with
a valid provider agreement that has its base of operation physically located in the geographic
catchment area specified in the contract and is the catchment area in which the individual lives.
Individuals who receive services in the CLASS program may request to transfer to another CMA
at any time.
As outlined in this section, the CMA is required to provide the following case management
services on an ongoing basis:
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assist the individual as necessary to maintain Medicaid eligibility;
conduct various tasks related to enrollment;
perform functions related to service planning;
monitor the provision of CLASS services;
protect the individual's rights;
intervene to assist individuals in crisis; and
coordinate the individual's CLASS services with non-CLASS services as necessary
through the employment of person-centered planning techniques.
CLASS program services as a whole enhance an individual's integration in the community and
prevent admission to an institution while maintaining and improving independent functioning.
2110 Base of Operation
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Revision 11-3; Effective November 18, 2011
CLASS program providers must have a base of operation that includes a physical location and
normal operating hours in each geographic catchment area for which they have a contract to
provide CLASS program services.
1. A base of operation is a place in which business, clerical or professional activities are
conducted. Each base of operation must:
o maintain individual records for the CLASS program contract in the catchment
area;
o maintain personnel records for personnel who provide CLASS program services
to individuals served in the catchment area;
o be staffed by qualified employees who have completed CLASS program training
and can readily become familiar with the individuals being served in the
catchment area; and
o maintain adequate staff to provide services and to supervise the provision of
services within the catchment area.
2. Providers must identify the base of operation's normal operating hours. If the base of
operations is closed during its normal operating hours or between the hours of 8:00 a.m.
and 5:00 p.m. Monday through Friday, the provider must:
o post a notice in a visible location outside the base of operations to provide
information regarding how to contact the person in charge; and
o leave a message on an answering machine or similar electronic mechanism to
provide information regarding how to contact the person in charge.
2120 CMA Staff Training Requirement
Revision 12-1; Effective January 13, 2012
2121 Initial Training for Staff with Direct Contact
Revision 13-2; Effective September 6, 2013
Upon hire, all Case Management Agency (CMA) staff whose job functions might involve direct
contact with individuals receiving Community Living Assistance and Support Services (CLASS)
must complete one of the following within 60 calendar days of the employee beginning to
provide CLASS program services:
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In-person CLASS Provider Training provided by DADS; or
Training developed by CMA that includes, at a minimum:
o CLASS program overview;
o Person-centered planning;
o Philosophy and values of community integration;
o Overview of related conditions and CLASS program eligibility criteria;
o Service Planning Team (SPT) process;
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Utilization Review process;
Consumer Directed Services; and
Individuals' rights and responsibilities including:
 Fair hearing process;
 CMA's complaints process;
 Mandatory participation requirements; and
 Abuse, neglect and exploitation characteristics and reporting information.
The CMA could choose to conduct training at its location to meet the above requirements within
60 days of hiring the service provider. CMA staff who develop the curriculum used for initial
training must have attended and successfully completed the CLASS Provider Training. The
CMA must have a record to verify that the trainer has attended the CLASS Provider Training.
The CMA may choose to send new employees to CLASS Provider Training at the next
opportunity offered by DADS to further reinforce training provided by the CMA.
Documentation of completion of required training must include, at a minimum:
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CLASS Provider Training completion certificate with the name of the employee, signed
by DADS; or
Written documentation of completion of CMA's training that includes:
o Training topics covered;
o Method of training (i.e., reading, video, discussion, etc.);
o Name(s) and qualifications of instructor(s);
o Name of the trainee;
o Date the training was completed;
o Signature and date of the instructor(s); and
o Signature and date of the trainee verifying completion.
If a CMA develops curriculum to meet CLASS training requirements, the curriculum and
training materials used must be maintained by CMA and be available to DADS employees
during a contract monitoring review.
2122 Initial and Annual Training for All CMA Staff
Revision 13-2; Effective September 6, 2013
All Case Management Agency (CMA) staff must complete the training described below within
60 calendar days of employment and at least every 12 months thereafter:
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Abuse, Neglect and Exploitation (ANE)
o review of the statute on ANE at Human Resources Code, Chapter 48, §48.002 (2,
3 and 4);
o signs and symptoms of ANE;
o reporting requirements of ANE; and
o how to report abuse and neglect to DFPS at
www.dfps.state.tx.us/Contact_Us/report_abuse.asp.
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Rights and Responsibilities of Individuals
o information about the rights of the individual who receives CLASS services as
outlined in the DADS Consumer Rights and Services booklet; and
o review of CLASS rules in Chapter 45, Subchapter C, §45.301 and §45.302
concerning the Rights and Responsibilities of an Individual.
If a CMA develops curriculum to meet CLASS training requirements, the curriculum and
training materials used must be maintained by CMA and available to DADS employees during a
contract monitoring review.
2200 Eligibility
Revision 12-1; Effective January 13, 2012
The case manager is responsible for verifying the individual's eligibility for the CLASS program
by ensuring the following criteria are met:
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The individual is financially eligible for Medicaid because the individual receives
Supplemental Security Income (SSI) cash benefits or is determined by the Health and
Human Services Commission (HHSC) to be financially eligible for Medicaid.
The individual demonstrates a need for habilitation.
The individual has an Individual Plan of Care (IPC) cost for CLASS program services at
or below $114,736.07.
The individual is not enrolled in another Medicaid waiver program.
The individual resides in their own home or family home.
The Case Management Agency (CMA) must verify Medicaid eligibility on a monthly basis. In
addition, DADS informs CMA monthly in writing about the loss of Medicaid eligibility for any
of the individuals assigned to the CMA. DADS provides the following information:
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individual's name;
Medicaid number; and
effective date of loss of Medicaid eligibility.
When the CMA receives notice of an individual's impending loss of Medicaid eligibility, the
CMA must work proactively with the individual/legally authorized representative (LAR) to
ensure Medicaid eligibility is re-established as soon as possible. For individuals who lose
Medicaid eligibility, the CMA must offer direct assistance to the individual/LAR as necessary to
help the individual re-establish eligibility. The CMA must follow up with the individual/LAR at
least every two weeks regarding progress toward completion of necessary steps until Medicaid
eligibility is re-established or the individual is terminated from the CLASS program.
Program services may be terminated if the individual does not meet any eligibility criteria as
outlined in Texas Administrative Code (TAC) §45.406. See Section 2400, Denial, Reduction,
Suspension and Termination, for more information on termination of services.
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2300 Service Planning
Revision 13-2;
The case manager facilitates Service Planning Team (SPT) meetings. The SPT process
emphasizes the provision of supports and services necessary for the individual's functioning and
to maintain integration in the community. After all requirements for eligibility are met, and at
least annually thereafter, the case manager, the applicant/individual/legally authorized
representative (LAR), Direct Service Agency (DSA) representative(s) (as defined in Section
3300, Service Planning), and other people requested by the applicant/individual/LAR meet to
develop a proposed Form 3621, CLASS – Individual Plan of Care (IPC).
The proposed IPC must specify:
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the type of CLASS program services to be provided to the individual;
the number of units of each CLASS program service;
the estimated annual cost of all CLASS program services; and
other services or supports to be provided to the individual through sources other than the
CLASS program.
As part of the service planning process, the SPT will also develop an Individual Program Plan
(IPP) on Form 8606, Individual Program Plan (IPP).
An IPP is needed for each CLASS program service listed on the proposed IPC. Each IPP
describes:
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CLASS program services to be provided;
frequency of service provisions;
observable and measurable goals and objectives;
title of person responsible for goals and objectives;
justification for services based on needs identified by the SPT;
duration of services; and
support services provided through non-waiver resources.
SPT notes are created by the case manager during the SPT meeting. The SPT notes summarize
the outcome of the meeting and must include, at a minimum:
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each service being requested by the SPT;
planned service schedules for each service requested;
units/amount of each service requested; and
signature and date of each SPT member present at the meeting.
If the individual requests a therapeutic service (e.g., occupational therapy, physical therapy,
speech and language pathology, behavioral support, audiology, dietary service, auditory
enhancement training or any specialized therapy), the case manager must initiate Form 8606-A,
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Therapy Justifications – Attachment to IPP, based on the deliberations of the SPT. The case
manager must coordinate the completion of Attachment A with the appropriate professional.
The case manager is responsible for initiating revisions to the individual's IPC as determined
necessary throughout each plan year. The case manager will submit all proposed IPCs to DADS.
The case manager must, on an ongoing basis, assist individuals in gaining access to needed
CLASS services and other services and supports, including medical, social and educational
resources, regardless of the funding source for the services and supports.
All requests from DADS related to the UR process must be submitted within the time frame
outlined in Section 5000.
Within 10 business days from DADS authorization, the CMA is responsible for providing a copy
of each of the following DADS authorized documents to all SPT members including the
financial management services agency (FMSA), if the individual receives a service through the
CDS option:
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authorized IPC (Form 3621);
IPP(s) Form 8606);
SPT notes;
Therapy Justifications - Attachment to IPP, if applicable (Form 8606-A)
Request for Adaptive Aids, Medical Supplies, Minor Home Modifications or Dental
Services/Sedation, if applicable, (Form 3660)
Habilitation Training Plan, if applicable (Form 3597) and
additional documentation as agreed upon by the SPT.
2310 Enrollment
Revision 13-2; Effective
At the time an applicant receives a written offer of a CLASS program vacancy from DADS, the
applicant must select a Case Management Agency (CMA) within 30 calendar days after the date
of the written offer from DADS. DADS notifies the selected CMA the applicant has chosen the
agency to provide case management services according to the DADS Selection Determination
document. The CMA completes Form 3657, Pre-Enrollment Assessment, assists the applicant
with the application process for Medicaid eligibility, if needed, and provides general information
regarding the CLASS Medicaid waiver program to CLASS applicants. All applicable forms
related to enrollment activities are included in the table at the end of this section.
Upon notification that the applicant has selected the CMA, a case manager must be assigned to
the applicant. The CMA must have a written process that ensures case managers are or can
readily become familiar with individuals to whom they are not ordinarily assigned, but to whom
they may be required to provide case management.
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The case manager must complete the following functions within 14 calendar days of the CMA's
receipt of the Selection Determination document from DADS:
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provide applicant/LAR with name and contact information, including an alternate contact
in case of absence of the case manager;
conduct an initial face-to-face, in-home visit with the applicant/LAR that must include
providing an oral and written explanation of:
o CLASS program services;
o the mandatory participation requirements;
o the Consumer Directed Services (CDS) option;
o the complaint process;
o if appropriate, provide information about cognitive rehabilitation therapy (CRT)
and assist individual to obtain a neurobehavioral or neuropsychological
assessment and plan of care from a qualified professional using Medicaid State
Plan;
o Form 8601, Verification of Freedom of Choice, designating CLASS services over
the institutional services;
o voter registration, if the individual is age 18 or older;
o determine an individual meets criteria for Transition Assistance Services (TAS) if
the individual is receiving institutional services:
 ensure the proper information is included on DADS Transition Assistance
Services (TAS) Assessment and Authorization form;
 send the completed form to DADS for authorization with the proposed
enrollment IPC;;
 send the authorized form to the TAS provider; and
 include the TAS and the monetary amount authorized by DADS on the
individual's proposed enrollment IPC;
provide an oral and written explanation to the individual/LAR describing that the DSA
may be requested to provide habilitation or out-of-home respite in a camp while the
individual is temporarily staying outside the catchment area in which the individual
resides, but within the state of Texas. The service period cannot exceed 60 consecutive
days;
complete Form 3657; and
verify residency to ensure the applicant lives in his own or family home that is located
within the catchment area for which the CMA has a current Community Services
Contract (Provider Agreement), to provide CLASS program services.
Cognitive Rehabilitation Therapy
CRT assists an individual in learning or relearning cognitive skills that have been lost or altered
because of damage to brain cells/chemistry in order to enable the individual to compensate for
the lost cognitive functions. Loss of cognitive functions qualifying an individual to receive CRT
occurs when an individual experiences a brain injury. CRT is provided when determined to be
medically necessary through an assessment conducted by an appropriate professional. CRT is
provided in accordance with the plan of care that was developed by the assessor.
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An acquired brain injury (ABI) is an injury to the brain that occurs after birth, is non-congenital
and non-degenerative, and that disrupts the normal function of the brain. The definition of ABI
also includes traumatic brain injury (TBI) and other brain injuries resulting from any anoxic
condition. Additional information on acquired brain injuries is located on the website for the
Health and Human Services Commission office on Acquired Brain Injuries at
http://www.hhsc.state.tx.us/hhsc_projects/abj/index.shtml
The case manager must complete the following functions within two business days following the
initial face-to-face assessment:
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evaluate the applicant's need for habilitation services;
assist with Medicaid eligibility processes, as necessary;
verify the individual is not enrolled in another 1915(c) Medicaid waiver program or any
other mutually exclusive services or programs (See Appendix III, DADS Operated
Program CLASS Mutually Exclusive List); and
provide the Direct Service Agency (DSA) with a completed Form 3657.
Within 30 calendar days of notification by the DSA of DADS approval of diagnostic/functional
eligibility for an individual as identified on Form 8578, Intellectual Disability/Related Condition
Assessment, the case manager must convene the SPT to develop the enrollment Individual Plan
of Care (IPC), Form 3621, CLASS – Individual Plan of Care (IPC).
The SPT should include, at a minimum, the applicant/LAR, case manager and a DSA
representative. The individual or LAR may request the SPT include professionals who are
qualified by certification or licensure, or training and experience in the habilitation needs of
people with related conditions, or directly involved in the delivery of services and supports to the
individual. . The SPT may include any other people requested by the individual/LAR. The SPT
will make every effort to accommodate these requests by the individual/LAR.
Form Resources
The following forms may need to be completed as part of the enrollment process:
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Form 1351, Request to Withdraw from the CLASS Application Process
Form 1577, Personal Care Services Selection
Form 1581, Consumer Directed Services Option Overview
Form 1582, Consumer Directed Services Responsibilities
Form 1583, Employee Qualification Requirements
Form 1584, Consumer Participation Choice
Form 1740, Service Backup Plan
Form 2067, Case Information
Form 3596, CLASS/DBMD – Habilitation Plan
Form 3597, CLASS – Habilitation Training Plan
Form 3598, CLASS – Individual Transportation Plan
Form 3621, CLASS – Individual Plan of Care
Form 3623, Approval of Application for CLASS
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Form 3625, CLASS – Documentation of Services Delivered
Form 3628, Provider Agency Model Service Backup Plan
Form 3657, Pre-Enrollment Assessment
Form 4800-D, DADS Fair Hearing Request Summary
Form 8001, Medicaid Estate Recovery Program Receipt Acknowledgement
Form 8598, Non-Waiver Services
Form 8601, Verification of Freedom of Choice
Form 8604, Transition Assistance Services (TAS) Assessment and Authorization
Form 8606, Individual Program Plan (IPP)
Form H1010, Texas Works Application for Assistance – Your Texas Benefits
Form H1200, Application for Assistance – Your Texas Benefits
Form H1350, Opportunity to Register to Vote
Form H3034, Disability Determination Socio-Economic Report
Form H3035, Medical Information Release/Disability Determination
Submission Standard — Enrollment
The following submission standards apply when submitting enrollment paperwork to DADS:
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Form 1577, Personal Care Services Selection (only applicable to applicants under the age
of 21)
Choice Lists for the CLASS Program
Form 3590, CLASS – Nursing Assessment
Form 3596, CLASS/DBMD – Habilitation Plan
Form 3597, CLASS – Habilitation Training Plan (only include if this specific service has
been proposed as part of an enrollment IPC)
Form 3598, CLASS – Individual Transportation Plan (only include if this specific service
has been proposed as part of an enrollment IPC)
Form 3621, CLASS – Individual Plan of Care
Form 3660, CLASS – Request for Adaptive Aids, Medical Supplies, Minor Home
Modifications or Dental Services/Sedation (only include if this specific service has been
proposed as part of an enrollment IPC)
Form 3849-A, Specifications for Adaptive Aids/Medical Supplies/Minor Home
Modifications, including bids (only include if funding for specifications has been
proposed as part of an enrollment IPC)
Form 8578, Intellectual Disability/Related Condition Assessment
Form 8598, Non-Waiver Services
Form 8601, Verification of Freedom of Choice
Form 8604, Transition Assistance Services (TAS) Assessment and Authorization (only
include if this specific service has been proposed as part of an enrollment/renewal IPC)
Form 8606, Individual Program Plan (IPP)
Form 8606-A, Therapy Justifications – Attachment to IPP (only include if this specific
service has been proposed as part of an enrollment IPC)
Submission Standard — Pre-enrollment
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The following submission standards apply when submitting paperwork containing funding
proposals for pre-enrollment efforts to DADS:
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Form 3625, CLASS – Documentation of Services Delivered;
Form 3657, Pre-Enrollment Assessment (partial assessment fee); or
Form 3621, CLASS – Individual Plan of Care (full assessment fee)
2320 Renewal
Revision 13-2;
The case manager must complete the following functions no less than 30 calendar days and no
more than 90 calendar days before the end of the current Individual Plan of Care (IPC) year:
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provide an oral and written explanation to the individual/LAR describing that the DSA
may be requested to provide habilitation or out-of-home respite in a camp while the
individual is temporarily staying outside the catchment area in which the individual
resides, but within the state of Texas. The service period cannot exceed 60 consecutive
days.
convene a Service Planning Team (SPT) to develop:
o a renewal IPC – the CLASS program services on the proposed renewal IPC must
meet the following standards:
 are necessary to protect the individual's health and welfare in the
community;
 address the individual's related condition;
 are not available to the individual through any other source, including the
Medicaid State Plan, other governmental programs, private insurance or
the individual's natural supports;
 prevent the individual's admission to an institution;
 are the most appropriate type and amount of CLASS program services to
meet the individual's needs; and
 are cost effective;
o a renewal Individual Program Plan (IPP) for each service proposed on the renewal
IPC; and
o a habilitation plan/habilitation training plan;
submit the proposed IPC, IPP, habilitation plan/habilitation training plan and intellectual
disability/related condition for review to DADS by mail; and
submit a copy of the proposed renewal IPC to the Financial Management Services
Agency (FMSA), if applicable.
Within ten business days of DADS transmission of the authorized IPC, as evidenced by the fax
transmittal date on the documents, the case manager must provide copies of the DADS
authorized IPC, IPPs, habilitation plan/habilitation training plan, SPT notes and intellectual
disability/related condition to all members of the SPT. The case manager must provide copies of
this documentation to any additional CLASS service providers (FMSA, Continued Family
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Services [CFS], and Support Family Services [SFS]), as necessary. The case manager must
maintain documentation of transmission of all necessary documents.
At DADS request, the Case Management Agency (CMA) must submit additional documentation
supporting the proposed renewal IPC to DADS within 10 business days after DADS requests it.
The date of DADS' request for additional documentation is determined by the date on Form
2067, Case Information, faxed to the CMA that requests the additional documentation.
If DADS notifies the CMA of the denial or reduction of a CLASS program service, see Section
2400, Denial, Reduction, Suspension and Termination.
Form Resources
The following forms may need to be completed as part of the renewal process:
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Form 1577, Personal Care Services Selection
Form 1581, Consumer Directed Services Option Overview
Form 1582, Consumer Directed Services Responsibilities
Form 1583, Employee Qualification Requirements
Form 1584, Consumer Participation Choice
Form 1586, Acknowledgement of Information Regarding Support Consultation Services
in the Consumer Directed Services (CDS) Option
Form 1740, Service Backup Plan
Form 2067, Case Information
Form 3596, CLASS/DBMD – Habilitation Plan
Form 3597, CLASS – Habilitation Training Plan
Form 3598, CLASS – Individual Transportation Plan
Form 3621, CLASS – Individual Plan of Care
Form 3624, Termination, Reduction or Denial of CLASS
Form 3625, CLASS – Documentation of Services Delivered
Form 3628, Provider Agency Model Service Backup Plan
Form 8578, Intellectual Disability/Related Condition Assessment (Pages 1 and 3)
Form 8598, Non-Waiver Services
Form 8601, Verification of Freedom of Choice
Form 8606, Individual Program Plan (IPP)
Form H1350, Opportunity to Register to Vote
Choice Lists for the CLASS Program
Submission Standard
The following submission standards apply when submitting renewal paperwork to DADS:
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Form 1577, Personal Care Services Selection (only applicable to applicants under the age
of 21)
Choice Lists for the CLASS Program
Form 3590, CLASS – Nursing Assessment
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Form 3596, CLASS/DBMD – Habilitation Plan
Form 3597, CLASS – Habilitation Training Plan (only include if this specific service has
been proposed as part of a renewal IPC)
Form 3598, CLASS – Individual Transportation Plan (only include if this specific service
has been proposed as part of a renewal IPC)
Form 3621, CLASS – Individual Plan of Care
Form 3660, Request for Adaptive Aids, Medical Supplies, Minor Home Modifications or
Dental Services/Sedation (only include if this specific service has been proposed as part
of a renewal IPC)
Form 3849-A, Specifications for Adaptive Aids/Medical Supplies/Minor Home
Modifications, including bids (only include Form 3849-A if funding for specifications
has been proposed as part of a renewal IPC)
Form 8578, Intellectual Disability/Related Condition Assessment (ID/RC)
Form 8598, Non-Waiver Services
Form 8606, Individual Program Plan (IPP)
Form 8606-A, Therapy Justifications – Attachment to IPP (only include if this specific
service has been proposed as part of a renewal IPC)
2330 Revision
Revision 13-2; Effective September 6, 2013
When the case manager is notified of a needed revision to the IPC, the case manager must
ensure:
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a proposed IPC revision includes an IPP for each service revised on the proposed IPC and
a revised habilitation plan, if applicable;
the CLASS program services on the proposed IPC revision must meet the following
standards:
o are necessary to protect the individual's health and welfare in the community;
o address the individual's related condition;
o are not available to the individual through any other source including the
Medicaid State Plan, other governmental programs, private insurance, or the
individual's natural supports;
o prevent the individual's admission to an institution;
o are the most appropriate type and amount of CLASS program services to meet the
individual's needs;
o are cost effective; and
the proposed IPC, IPPs and habilitation plan are submitted to DADS for review at least
30 calendar days before the effective date proposed by the SPT.
At DADS request, the Case Management Agency (CMA) must submit additional documentation
supporting the proposed IPC revision to DADS within 10 calendar days after DADS requests it.
The date of DADS' request for additional documentation is determined by the date on Form
2067, Case Information, faxed to the CMA that requests the additional documentation.
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If DADS notifies the CMA of the denial or reduction of a CLASS program service, see Section
2400, Denial, Reduction, Suspension and Termination.
Within five business days of DADS transmission of the authorized IPC, as evidenced by the fax
transmittal date on the documents, the case manager must provide copies of the DADS
authorized IPC, IPPs, habilitation plan/habilitation training plan, the Service Planning Team
(SPT) notes and intellectual disability/related condition (ID/RC) to all members of the SPT. The
case manager must provide copies of this documentation to any additional CLASS service
providers (FMSA, CFS, and SFS), as necessary. The case manager must maintain documentation
of transmission of all necessary documents.
Submission Standard
The following submission standards apply when submitting revision paperwork to DADS:
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Form 3590, CLASS – Nursing Assessment
Form 3596, CLASS/DBMD – Habilitation Plan (only include if this specific service has
been proposed as part of an IPC revision marked "New" or "Change" in Field 16a on
Form 3621)
Form 3597, CLASS – Habilitation Training Plan (only include if this specific service has
been proposed as part of an IPC revision marked "New" or "Change" in Field 16a on
Form 3621)
Form 3598, CLASS – Individual Transportation Plan (only include if this specific service
has been proposed as part of an IPC revision marked "New" or "Change" in Field 16a on
Form 3621)
Form 3621, CLASS – Individual Plan of Care
Form 3660, Request for Adaptive Aids, Medical Supplies, Minor Home Modifications or
Dental Services/Sedation (only include if this specific service has been proposed as part
of an IPC revision marked "New" or "Change" in Field 16a on Form 3621)
Form 3849-A, Specifications for Adaptive Aids/Medical Supplies/Minor Home
Modifications, including bids (only include if funding for specifications has been
proposed as part of an IPC revision)
Form 8598, Non-Waiver Services
Form 8606, Individual Program Plan (IPP) (only include if this specific service has been
proposed as part of an IPC revision marked "New" or "Change" in Field 16a on Form
3621)
Form 8606-A, Therapy Justifications – Attachment to IPP (only include if this specific
service has been proposed as part of an IPC revision marked "New" or "Change" in Field
16a on Form 3621)
2331 Immediate Jeopardy
When the Case Management Agency (CMA) receives written documentation from the Direct
Service Agency (DSA) indicating the DSA provided habilitation, respite, nursing, dental services
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or an adaptive aid that is not included on the individual's Individual Plan of Care (IPC) in
response to a situation of the individual's immediate jeopardy, the case manager must complete
and submit a proposed IPC revision, revised Individual Program Plans (IPPs) and documentation
to DADS within seven calendar days of notification by the DSA. The CMA must use the date of
the documentation provided by the DSA RN of the circumstances that determined immediate
jeopardy to the individual as the IPC eff date.
The documentation furnished to the CMA by the DSA must include:
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a description of circumstances necessitating the provision of the new service or the
increase in the amount of the existing service; and
documentation by a registered nurse of the nurse's determination the service was
necessary to prevent the individual's health and safety from being placed in immediate
jeopardy.
DADS authorizes the IPC only if, after reviewing the documentation, DADS determines the
service was necessary to prevent the individual's health and safety from being placed in
immediate jeopardy.
At DADS request, the CMA must submit additional documentation supporting the proposed IPC
revision to DADS within 10 calendar days.
Form Resources
The following forms may need to be completed as part of the revision process:








Form 1740, Service Backup Plan
Form 2067, Case Information
Form 3621, CLASS – Individual Plan of Care
Form 3596, CLASS/DBMD – Habilitation Plan
Form 3597, CLASS – Habilitation Training Plan
Form 3598, CLASS – Individual Transportation Plan
Form 3628, Provider Agency Model Service Backup Plan
Form 8606, Individual Program Plan (IPP)
2340 Transfer
Revision 13-2; Effective September 6, 2013
When the individual/legally authorized representative (LAR) notifies the case manager they wish
to be transferred to a different agency(s), the case manager must:


document in the individual's record the date the transfer request was received;
provide the individual/LAR with the most current selection determination document for
the applicable catchment area;
14



make transfer arrangements with the individual/LAR, the receiving Case Management
Agency (CMA), Direct Service Agency (DSA) or Financial Management Services
Agency (FMSA), as appropriate;
establish an effective date for the individual's transfer that is at least 14 calendar days
after the date of receiving notice of intent to transfer; and
coordinate with the agencies involved in the transfer to determine the number of needed
service units for each authorized service code.
The current CMA must submit the following to DADS before the effective date of the transfer:



the individual's currently authorized Individual Plan of Care (IPC)
Form 3621-T, CLASS – IPC Service Delivery Transfer Worksheet
Choice Lists for the CLASS Program
Form Resources
The following forms may need to be completed as part of the transfer process:



Form 2067, Case Information
Form 3621-T, CLASS – IPC Service Delivery Transfer Worksheet
Choice Lists for the CLASS Program
Submission Standard
The following submission standards apply when submitting transfer paperwork to DADS:


Form 3621-T, CLASS – IPC Service Delivery Transfer Worksheet
Choice Lists for the CLASS Program
2350 IPP Service Review
The case manager is responsible for ongoing monitoring of:


the provision of CLASS program services; and
the status of non-CLASS program services and supports.
The case manager must meet with the individual or legally authorized representative (LAR) in
the individual's home, or other location if services are not primarily provided in the individual’s
home, to review the Individual Plan of Care (IPC) at least every three months, from the effective
date of the most recent enrollment or renewal IPC and as needed during the IPC year. CMA
Individual Program Plan (IPP) service reviews will occur in accordance with the schedule in
Appendix X, Quarterly Due Dates Chart, of the CLASS Provider Manual from the effective date
of the most recent enrollment or renewal IPC. The fourth quarterly review of the IPC year is
combined with the meeting of the Service Planning Team (SPT) to develop a renewal IPC. The
15
SPT notes will document the development of the renewal IPC. The case manager must use Form
3595, IPP Service Review, to document the review of the services delivered to the individual
since the ninth month quarterly review.
The purpose of meeting the individual or LAR in the setting where services are delivered is to
allow the case manager to verify that services listed on the IPC are delivered as described in the
Individual Program Plan (IPP). This function is best accomplished by the case manager
observing CLASS services in the setting in which they are provided. Since most individuals
receive CLASS services in the home setting, the quarterly service reviews should occur in the
location where the majority of services are delivered.
While individuals or their LAR may request the case manager meet in locations other than their
own home/family home, case managers should remind them that a complete assessment of
services provided to the individual is required to be performed in the setting in which those
services are delivered. Case managers must document when and why an individual or LAR
refuses to meet in the home setting in the “General Comments” section of Form 3595.
During the quarterly service review face-to-face contact with the individual, the case manager
must complete Form 3595 to:





review the services received as documented on the IPC;
document progress or lack of progress toward goals/objectives as identified on the
IPP/IPC;
assess the individual's satisfaction with the provision of CLASS program services;
determine if the service backup plan was implemented and if it met the needs of the
individual and
identify any changes to the individual's needs to include any needed revisions to the
service backup plan.
The case manager is required to complete all sections of Form 3595 for CLASS services
provided to an individual. The case manager may choose to print only those pages that reflect the
services reviewed and provide them to the individual, the direct service agency (DSA) and any
additional CLASS service providers (FMSA, CFS, and SFS), as necessary.
If an individual's IPC includes any nursing services or habilitation, and any of those services are
not currently identified as requiring a service backup plan the case manager must discuss with
the individual or LAR whether any of those services may now be critical to the individual's
health and safety. If the case manager and individual/LAR determines a service may now be
critical to the individual's health and safety, the case manager must convene the service planning
team to discuss development of a service backup plan.
The case manager must also ask the individual/LAR if a service backup plan was implemented
during the most recent review period and discuss the implementation of the service backup plan
with the individual/LAR to determine whether or not the plan was effective;
16
If the service backup plan was implemented and determined to be ineffective, the case manager
must convene a service planning team meeting to revise the service backup plan.
If a change is requested by the individual during the quarterly service review, the case manager
is responsible for initiating any change(s) needed and convenes the SPT, as applicable, within
five business days after becoming aware that the individual's needs have changed.
Within five business days of the quarterly service review, the case manager is responsible for
providing copies of the service review to the individual, DSA and any additional CLASS service
providers (FMSA, CFS, and SFS), as necessary. The case manager must maintain documentation
of transmission of all necessary documents.
Form Resources
The following forms may need to be completed as part of the 90-day service review:



Form 2067, Case Information
Form 3595, IPP Service Review
Form 3621, CLASS – Individual Plan of Care
2400 Denial, Reduction, Suspension and Termination
Revision 13-2; Effective September 6, 2013
An individual whose CLASS program services are denied, reduced, suspended or terminated
must be given notice of adverse actions taken by DADS and is entitled to a fair hearing.
The CMA must obtain written authorization from DADS for all suspensions of CLASS program
services.
DADS issues a notice to the CMA of all denials of enrollment or terminations from the CLASS
program. The CMA must notify the individual, DSA, FMSA and SFS provider as applicable.
2410 Denial
Revision 13-2; Effective September 6, 2013
Denial is a DADS action that disallows:



an individual's request for enrollment in the CLASS program;
a service requested on the IPC that was not authorized on the prior IPC; or
a portion of the amount or level of the service requested on the IPC that was not
authorized on the prior IPC.
Denial of a Request for Enrollment into the CLASS Program
17
DADS denies an individual's request for enrollment into the CLASS program if:


the individual does not meet the eligibility criteria described in §45.201, Eligibility
Criteria; or
the DSAs serving the catchment area in which the individual resides are not willing to
provide CLASS program services to the individual because they have determined that
they cannot ensure the individual's health and safety.
If DADS denies a request for enrollment, DADS sends written notice to the individual or LAR of
the denial of the individual's request for enrollment into the CLASS program and includes in the
notice the individual's right to request a fair hearing in accordance with §45.301, Individual's
Right to a Fair Hearing. DADS sends a copy of the written notice to the individual's DSA, CMA
and, if selected, FMSA.
Denial of a CLASS Program Service
DADS denies a CLASS program service on an individual's IPC if services:






are not necessary to protect the individual's health and welfare in the community;
do not address the individual's related condition;
are available to the individual through any other source including the Medicaid State
Plan, other governmental programs, private insurance or the individual's natural supports;
do not prevent the individual's admission to an institution;
are not the most appropriate type and amount of CLASS program services to meet the
individual's needs; or
are not cost effective.
If DADS denies a CLASS program service on an individual's IPC, DADS notifies the CMA in
writing. Upon receipt of DADS written notice of denial of a CLASS program service, the CMA
must send Form 3624, Termination, Reduction or Denial of CLASS, to the individual/LAR of
the denial of the service, copying the individual's DSA and, if selected, FMSA or SFS provider.
Form Resources
The following forms may need to be completed as part of a suspension denial of services:



Form 2067, Case Information
Form 3624, Termination, Reduction or Denial of CLASS
Form 4800-D, DADS Fair Hearing Request Summary
Submission Standard
The following submission standards apply when submitting a request for an appeal to DADS:

Form 3624, Termination, Reduction or Denial of CLASS
18



Written documentation established by the CMA in the event of a verbal request for
appeal by individual/LAR (only if individual/LAR did not exercise their appeal rights
using Form 3624)
Form 4800-D, Fair Hearing Request Summary
Form 4800-DA, 4800-D Addendum (only if there are more than three other hearing
participants who require notification of a hearing)
2420 Reduction
Revision 13-2; Effective September 6, 2013
Reduction is a DADS action taken as a result of a review of an IPC that decreases the amount or
level of a service authorized by DADS on a prior IPC.
DADS will perform utilization review on all IPCs that meet criteria outlined in Section 5000,
Utilization Review (UR). All services and units of service included on a proposed IPC must be
justified by the SPT.
DADS CLASS Program staff review the IPC to ensure the services on the IPC:





are necessary to protect the individual's health and welfare in the community;
supplement rather than replace the individual's natural supports and other non-CLASS
program services and supports for which the individual may be eligible;
prevent the individual's admission to an institution;
are the most appropriate type and amount of services to meet the individual's needs; and
are cost effective.
The case manager has the responsibility to gather the following information for the DADS
CLASS program staff:




assessments,
reports,
professional observations, or
other resources.
The case manager must summarize this information using the appropriate IPP.
As necessary during the review of a proposed IPC, DADS CLASS program staff will ask case
managers to provide additional justification if the initial information submitted with a proposed
IPC is not sufficient to demonstrate the need for requested services or does not meet
requirements for a CLASS IPC as outlined in Section 1000, Introduction. If information
submitted to DADS by the case manager does not provide sufficient information to justify
requested units of services, DADS will modify the IPC by reducing the number of units of
services as necessary and will notify the CMA of the reduction in writing.
19
If an individual's services are reduced, the CMA must notify the individual and provide a copy of
the notification to the DSA, FMSA and SFS provider, as applicable, of the documentation of the
reason for the reduction. Upon receipt of a written notice from DADS proposing to reduce a
service, the CMA must inform the individual or LAR of DADS decision. The CMA informs the
individual of the right to request a fair hearing.
The case manager sends written notice on Form 3624, Termination, Reduction or Denial of
CLASS, to the individual allowing 12 days for the individual to respond before taking any action
to reduce services.
If the individual or LAR requests a fair hearing before the effective date of the reduction of a
CLASS program service, as specified in the written notice, the DSA must provide the service to
the individual in the amount authorized in the prior IPC while the appeal is pending.
Form Resources
The following forms may need to be completed as part of a suspension reduction of services:



Form 2067, Case Information
Form 3624, Termination, Reduction or Denial of CLASS
Form 4800-D, Fair Hearing Request Summary
Submission Standard
The following submission standards apply when submitting a request for an appeal to DADS:




Form 3624, Termination, Reduction or Denial of CLASS
Written documentation established by the CMA in the event of a verbal request for
appeal by individual/LAR (only if individual/LAR did not exercise their appeal rights
using Form 3624)
Form 4800-D, Fair Hearing Request Summary
Form 4800-DA, 4800-D Addendum (only if there are more than three other hearing
participants who require notification of a hearing)
2430 Suspension
Individuals may not receive CLASS program services during a period of time in which they are
admitted to a facility listed in this section. Individuals must be suspended without advance
notification from CLASS program services until such time as the individual returns to their own
or family home or are terminated from the CLASS program. The individual is not eligible for
continuation of CLASS services until the fair hearing process is completed because suspension
of an individual's services is effective the date the individual was temporarily admitted to one of
the facilities listed below or leaves the state. Therefore, no advance notification can be provided
to the individual of the suspension.
20
Within two business days after the CMA becomes aware of a situation that necessitates an
individual's CLASS program services to be suspended, the CMA must send a written request for
suspension with written supporting documentation to DADS CLASS program staff.
DADS notifies the individual's CMA in writing of whether it authorizes a suspension of CLASS.
Suspension is a DADS action taken:


upon an individual's admission for any length of time up to 180 consecutive calendar
days to one of the following facilities:
o an ICF/IID licensed or subject to being licensed in accordance with Texas Health
and Safety Code, Chapter 252, or certified by DADS, unless the individual is
receiving out-of-home respite in the facility;
o a nursing facility licensed or subject to being licensed in accordance with Texas
Health and Safety Code, Chapter 242, unless the individual is receiving out-ofhome respite in the facility;
o an assisted living facility licensed or subject to being licensed in accordance with
Texas Health and Safety Code, Chapter 247;
o a residential child-care operation licensed or subject to being licensed by the
Department of Family and Protective Services (DFPS), unless it is a foster family
home or a foster group home;
o a facility licensed or subject to being licensed by the Department of State Health
Services (DSHS);
o a facility operated by the Department of Assistive and Rehabilitative Services
(DARS); or
o a residential facility operated by the Texas Youth Commission, a jail or prison; or
upon an individual leaving the state for up to 180 consecutive calendar days.
Upon receipt of a written notice from DADS authorizing the suspension of CLASS Program
services, the CMA must send the written notice of suspension to the individual/LAR, DSA and
FMSA, if applicable. The written notice includes the individual's right to request a fair hearing.
The period of suspension is the length of the admission to the facility or the time spent in another
state. An individual may remain on suspension from CLASS for up to 180 calendar days. DADS
may extend an individual's suspension for 30 calendar days upon the CMA's request.
Form Resources
The following forms may need to be completed as part of a suspension of services:



Form 2067, Case Information
Form 3624, Termination, Reduction or Denial of CLASS
Form 4800-D, Fair Hearing Request Summary
Submission Standard
The following submission standards apply when submitting a request for an appeal to DADS:
21




Form 3624, Termination, Reduction or Denial of CLASS
Written documentation established by the CMA in the event of a verbal request for
appeal by individual/LAR (only if individual/LAR did not exercise their appeal rights
using Form 3624)
Form 4800-D, Fair Hearing Request Summary
Form 4800-DA, 4800-D Addendum (only if there are more than three other hearing
participants who require notification of a hearing)
2440 Termination
Revision 11-1; Effective June 13, 2011
Termination is a DADS action that results in the loss of the individual's authorized services in
the CLASS program.
2441 Termination With Advanced Notice
Revision 13-2; Effective September 6, 2013
DADS terminates an individual's CLASS program services if:




the individual does not meet program eligibility criteria;
the individual is admitted for more than 180 consecutive calendar days to one of the
following facilities:
o an ICF/IID licensed or subject to being licensed in accordance with Texas Health
and Safety Code, Chapter 252 or certified by DADS, unless the individual is
receiving out-of-home respite in the facility;
o a nursing facility licensed or subject to being licensed in accordance with Texas
Health and Safety Code, Chapter 242, unless the individual is receiving out-ofhome respite in the facility;
o an assisted living facility licensed or subject to being licensed in accordance with
Texas Health and Safety Code, Chapter 247;
o a residential child-care operation licensed or subject to being licensed by the
Department of Family and Protective Services (DFPS), unless it is a foster family
home or a foster group home;
o a facility licensed or subject to being licensed by the Department of State Health
Services (DSHS);
o a facility operated by the Department of Assistive and Rehabilitative Services
(DARS);
o a residential facility operated by the Texas Juvenile Justice Department, a jail or
prison; or
the individual leaves the state for more than 180 consecutive calendar days and DADS
has not extended the individual's suspension;
Direct Service Agencies (DSAs) serving the catchment area in which the individual
resides are not willing to provide CLASS program services to the individual because they
have determined that they cannot ensure the individual's health and safety; or
22

the individual refuses to comply with a mandatory participation requirement as follows:
o not completing and submitting an application for Medicaid financial eligibility to
the Health and Human Services Commission (HHSC) within 30 calendar days
after the case manager's initial face-to-face, in-home visit (Note: If an individual
or legally authorized representative (LAR) does not submit a Medicaid
application to HHSC within 30 calendar days of the case manager's initial face-toface, in-home visit as required but is making good faith efforts to complete the
application, the Case Management Agency (CMA) may extend this time frame in
30 calendar-day increments as approved by DADS CLASS program staff.);
o not participating with the Service Planning Team (SPT) to:
 develop an enrollment Individual Plan of Care (IPC);
 renew and revise the IPC and Individual Program Plans (IPPs);
o not reviewing, agreeing to, signing and dating an IPC and IPPs;
o not using natural supports and other non-CLASS program services and supports
for which the individual may be eligible before using CLASS program services;
o not cooperating with the CMA and DSA in the delivery of CLASS program
services listed on the individual's IPC, including:
 working with the CMA and DSA in scheduling meetings;
 attending scheduled meetings with the case manager or service provider;
 being available to receive the CLASS program services;
 notifying the CMA or DSA in advance if the individual or LAR is unable
to attend a scheduled meeting or is unavailable to receive services in the
individual's own or family home;
 admitting CMA and DSA representatives to the individual's own home or
family home for a scheduled meeting or to receive CLASS program
services;
o not cooperating with the DSA's service providers to ensure progress toward
achieving the goals and objectives described in the IPP for each CLASS program
service listed on the IPC;
o not paying a required copayment in a timely manner when found by HHSC to be
financially eligible for CLASS program services based on the special institutional
income limit;
o not completing the procedures for redetermining eligibility for Medicaid, as
described in the Medicaid for the Elderly and People with Disabilities Handbook;
o engaging in criminal behavior in the presence of the case manager or service
provider;
o permitting a person present in the individual's own or family home to engage in
criminal behavior in the presence of the service provider or case manager;
o acting in a manner that is threatening to the health and safety of the case manager
or service provider;
o permitting a person present in the individual's own or family home to act in a
manner that is threatening to the health and safety of the case manager or service
provider;
o exhibiting behavior or permitting a person present in the individual's residence to
exhibit behavior that places the health and safety of the case manager or service
provider in immediate jeopardy;
23
o
o
o
initiating or participating in fraudulent health care practices;
engaging in behavior that endangers the individual's health or safety; and
permitting a person present in the individual's own home or family home to
engage in behavior that endangers the individual's health or safety.
Within two business days after the CMA becomes aware of one of the situations described
above, the CMA must send a written request of proposed CLASS termination to DADS. The
request must be accompanied by documentation supporting the proposed termination.
If termination of services is requested based on a determination by the DSA that it cannot ensure
the individual's health and safety, the CMA must include in the request specific reason(s) why
the DSA determines it cannot ensure the individual's health and safety.
DADS notifies the individual's CMA in writing using Form 3624, Termination, Reduction or
Denial of CLASS, or written notice from DADS, of whether it authorizes the proposed
termination of CLASS program services.
Upon receipt of DADS notification authorizing a proposed termination of CLASS program
services, the CMA must send written notice of the termination of CLASS program services to the
individual or LAR within two business days. The CMA must send a copy of the termination
notice to the individual's DSA and, if selected, Financial Management Services Agency (FMSA)
and Support Family Service Agency (SFS) provider. The CMA must include in the notice the
individual's right to request a fair hearing.
In the event CLASS program services are terminated due to an individual's IPC cost being over
$114,736.07, DADS sends written notice to the individual or LAR of the proposal to terminate
CLASS program services and includes the individual's right to request a fair hearing in the
notice. DADS sends a copy of the written notice to the individual's DSA, CMA, and if selected,
FMSA.
If a CMA becomes aware an individual has not complied with a mandatory participation
requirement described in this section, the CMA must immediately attempt to resolve the
situation, including facilitating at least one face-to-face meeting with the SPT. If, after making
attempts to resolve the situation, the CMA determines that the situation cannot be resolved, the
CMA must request in writing that DADS terminate CLASS program services for the individual.
The request must be sent to DADS within two business days of the CMA's determination the
situation cannot be resolved and be supported by written documentation. The written
documentation must include a description of:


the situation that resulted in the request to terminate CLASS program services; and
the attempts by the CMA and DSA to resolve the situation, including face-to-face
meetings with the individual or LAR.
The CMA will not provide notice of a termination of CLASS to an individual for whom DADS
has terminated due to an IPC cost being over $114,736.07. DADS will provide notice to
individuals in this situation directly.
24
If the individual or LAR requests a fair hearing before the effective date of a proposed
termination of CLASS program services, the DSA must provide services to the individual in the
amounts authorized in the IPC while the appeal is pending.
2442 Termination Without Advanced Notice
Revision 13-2; Effective September 6, 2013
DADS terminates an individual's CLASS program services without advanced notice if any of the
following situations exist:





the CMA or DSA has factual information confirming the death of the individual;
the CMA or DSA receives a clearly written statement signed by the individual that the
individual no longer wishes to receive CLASS program services;
the individual's whereabouts are unknown and the post office returns mail directed to him
or her by the CMA or DSA, indicating no forwarding address;
the CMA or DSA establishes the individual has been accepted for Medicaid services by
another state; or
an individual or a person in the individual's residence exhibits behavior that places the
health and safety of the CMA's case manager or a DSA's service provider in immediate
jeopardy. See Section 2443, Immediate Jeopardy.
Within two business days after the CMA becomes aware of a situation such as described above,
the CMA must send a written request to terminate CLASS program services to DADS. The
written request must be accompanied by documentation supporting the request.
DADS notifies the individual's CMA in writing of whether it authorizes the termination of
CLASS program services. Upon receipt of a written notice from DADS authorizing the
termination of CLASS program services, the CMA must send written notice to the individual or
LAR of the termination. The CMA must also send a hard copy of the termination notice to the
individual's DSA and, if selected, FMSA and SFS provider. The CMA must include in the notice
the individual's right to request a fair hearing.
2443 Immediate Jeopardy
Revision 13-2; Effective September 6, 2013
DADS may terminate an individual's CLASS program services if an individual or a person in the
individual's residence exhibits behavior that places the health and safety of the CMA's case
manager or a DSA's service provider in immediate jeopardy.
If a CMA or DSA becomes aware a situation exists that places the health and safety of the
individual's case manager or DSA service provider in immediate jeopardy, the CMA or DSA
must:
25


immediately file a report with the appropriate law enforcement agency and, if
appropriate, make an immediate referral to DFPS; and
notify DADS, CMA and DSA by telephone of the situation no later than one business day
after the CMA or DSA becomes aware of the situation.
The CMA and DSA must attempt to resolve the situation. If, after making attempts to resolve the
situation, the CMA determines that the situation cannot be resolved, the CMA must, within two
business days after the CMA becomes aware of the situation, send a written request to terminate
CLASS program services to DADS. The written request must be accompanied by:



a description of the situation that resulted in the request to terminate the individual's
CLASS program services;
a detailed description of the attempts by the CMA to resolve the situation; and
if available, a copy of any report issued by a law enforcement agency or DFPS regarding
the situation.
DADS notifies the individual's CMA in writing of whether it authorizes the proposed termination
of CLASS program services.
Upon receipt of written notice from DADS authorizing the termination of CLASS program
services, the CMA must, no later than the date of the termination of services, send written notice
to the individual or LAR of such termination. The CMA must provide a hard copy of the
termination notice to the individual's DSA and, if selected, FMSA and SFS provider. The CMA
must include in the notice the individual's right to request a fair hearing.
The CMA and DSA must maintain documentation of completion of these requirements in the
individual's record.
Form Resources
The following forms may need to be completed as part of termination of services:



Form 2067, Case Information
Form 3624, Termination, Reduction or Denial of CLASS
Form 4800-D, Fair Hearing Request Summary
Submission Standard — Termination
The following submission standards apply when submitting termination paperwork to DADS:



Form 3621, CLASS – Individual Plan of Care
Form 3624, Termination, Reduction or Denial of CLASS
Documentation of circumstances that support the termination of CLASS services.
Submission Standard — Appeal
26
The following submission standards apply when submitting a request for an appeal to DADS:




Form 3624, Termination, Reduction or Denial of CLASS
Written documentation established by the CMA in the event of a verbal request for
appeal by individual/LAR (only if individual/LAR did not exercise their appeal rights
using Form 3624)
Form 4800-D, Fair Hearing Request Summary
Form 4800-DA, 4800-D Addendum (only if there are more than three other hearing
participants who require notification of a hearing)
27