June 5th, 2023
HHSC’s Response to Three Recent ISS-Related Questions From Providers
Question 1: May an Individualized Skills and Socialization (ISS) provider charge families for after-hour care? Many times families cannot get off work at the time the program closes/services stop. Some providers will keep their doors open until 5 or 6 (with staff present of course), until families get off work. In these cases, the ISS providers charge families for that service.
HHSC’s Response: If the individualized skills and socialization provider is also the program provider, the program provider would not be allowed to charge additional fees outside of the established HCS Waiver Program Payment rates, located here. According to 40 TAC §9.178(o):
(o) The program provider must not assess charges against the individual’s personal funds for costs for items or services reimbursed through the HCS Program or through CFC.
Additionally, according to 26 TAC §263.2015:
The service limit for the combined total of on-site, off-site, and in-home individualized skills and socialization is:
(1) 1560 hours during an IPC year;
(2) six hours per calendar day; and
(3) five days per calendar week.
If the individualized skills and socialization provider is a contractor of the program provider, the provider’s costs must be considered reasonable and necessary in regard to the Medicaid cost/accountability reports. Unless the program provider agrees to pay a higher amount, the individualized skills and socialization provider must provide the service at or below the direct services portion of the applicable HCS Program rate.
According to 40 TAC §9.177(b):
(b) The program provider must employ or contract with a person or entity of the individual’s or LAR’s choice in accordance with this subsection.
(1) Except as provided by paragraph (2) of this subsection, the program provider must employ or contract with a person or entity of the individual’s or LAR’s choice to provide an HCS Program service or CFC service to the individual if that person or entity:
(A) is qualified to provide the service;
(B) unless the program provider agrees to pay a higher amount, provides the service at or below:
(i) for any service except CFC ERS, the direct services portion of the applicable HCS Program rate; and
(ii) for CFC ERS, the reimbursement rate; and
(C) is willing to contract with or be employed by the program provider to provide the service in accordance with this subchapter.
As part of agreeing to provide the HCS Program service at the direct services portion of the applicable HCS Program rate, the individualized skills and socialization provider would not be allowed to charge an individual or family additional charges outside what is reimbursed through the HCS Program. (This means, the provider can pay all of the direct and indirect portions of the rate to the ISS provider if they want to or more, but they don’t have to pay more than the direct portion of the rate if they don’t want to. Many HCS/TxHmL providers choose to pay all of the rate amount, the direct and indirect side both, but most likely are not paying more than the total rate as this would not be feasible or affordable for many HCS providers.)
Question 2: According to the rules, a person may receive in-home ISS assuming certain criteria are met/justifications secured. Provision of the service does not require a license. If the person wants to also engage in off-site activities, such must be provided by a licensed ISS. In these cases,
~Can (as an example) the HH provider obtain a license for off-site only and provide the service as long as the HH provider was not the person delivering the service?
HHSC’s Response: In accordance with the HCS Billing Requirements, Section 43102.7 a host home/companion care provider is prohibited from being the service provider of in-home individualized skills and socialization. There is no prohibition on the host home/companion care provider being a service provider of on-site or off-site individualized skills and socialization but those services cannot be provided in the individual’s residence. The host home/companion care provider would need to either be employed by an individualized skills and socialization provider or obtain an individualized skills and socialization license.
~ Can the individual (again one who has a justification for in-home ISS) attend an ISS just to participate in off-site ISS only, or must that service be provided in an off-site only licensed ISS ?
HHSC’s Response: Yes, an individual who has a justification to receive in-home individualized skills and socialization may choose to also receive off-site individualized skills and socialization at a facility that provides both on-site and off-site individualized skills and socialization. It is not required that they receive off-site through an off-site only licensed individualized skills and socialization facility.
~ Can the program provider for an individual obtain an off-site only ISS license so the individual can participate in off-site ISS activities as long as the service provider of such is not the HH provider? And if so, could the person providing the in-home ISS work for or contract with the provider to provide off-site ISS to the individual?
HHSC’s Response: Yes, a program provider may become a licensed off-site only individualized skills and socialization provider so that an individual can participate in off-site individualized skills and socialization activities. The service provider providing in-home individualized skills and socialization would be allowed to become an employee or contractor of the program provider owned off-site only individualized skills and socialization provider, as long as they met all other service provider requirements outlined in program rule and in the HCS Program Billing Requirements.
Question 3: Concerning ISS notes, it’s been reported by some providers that some HHSC or TMHP reviewers have told them that the ISS notes cannot be handwritten rather must be electronic. Is that true? And if so, where is that stated?
HHSC’s Response: There is no requirement that service delivery logs for on-site, off-site, or in-home individualized skills and socialization must be electronic over handwritten. HCS Policy does not specify the modality of service delivery log notes, only that the written documentation must be legible. According to Section 3810 of the HCS Billing Requirements:
3810 General Requirements
Revision 23-2; Effective April 1, 2023
(a) Legible A program provider must have written, legible documentation to support a service claim.
January 13th, 2023
ISS FAQs: Updated January 13th, 2023
August 23rd, 2022
Frequently Asked Questions HHSC shared during the ISS draft rules webinar on August 23rd, 2022.
These are questions received during the ISS webinar on July 19th, 2022
Q1: Will current day hab providers be grandfathered into the new
program? Or do they have to be program provider to have a day hab
contract with HHSC?
A1: No, Day Hab Providers are not grandfathered into the Individualized Skills and
Socialization program. Any provider who is interested in delivering Individualized
Skills and Socialization services must obtain a Day Activity Health Services or DAHS
– Individualized Skills and Socialization service category license, even those who
are currently providing day habilitation services.
Q2: Are the off-site activities generated from the individual PDPs or does the
ISS facility plan the activities?
A2: Off-site activities are generated from the individual’s Individual Plan of Care
and Individual Program Plan in the DBMD waiver program. In TxHmL and HCS, an
Individualized Skills and Socialization provider must provide off-site Individualized
Skills and Socialization in accordance with an individual’s PDP, IPC, and
implementation plan.
Q3: If the in-home service provider does not need to be an ISS
provider, does that mean that they can be a parent?
A3: A person who meets the Service Provider Qualifications for In-Home
Individualized Skills and Socialization, including a parent of an adult child
can provide Individualized Skills and Socialization.
Q4: What is the enhanced staffing rate? How does that work?
A4: An enhanced staffing rate is available in the HCS and TxHmL Programs
for an individual who requires more service provider support than the
individual would receive with the individual’s assigned LON. The requirement
for additional support may be because of the individual’s mobility, medical,
or behavioral needs. The program provider may request the enhanced
staffing rate for an individual with an LON 1 or LON 5 in the HCS Program, or
any LON in the TxHmL Program.
Q5: If the PDP do not specify how often a client needs to go out, will that be up
to the discretion of the individualized skills organization to decide how often
they go out?
A5: It is the individual’s choice for how they choose to receive off-site Individualized
Skills and Socialization and off-site Individualized Skills and Socialization must align with
the individual’s PDP, IPC, IP, and in DBMD the individual’s IPP.
Q6: Do we need to provide meals and snacks? Have a paid nurse on site? Can it
be an LVN?
A6: An Individualized Skills and Socialization provider does not need to provide meals
and snacks to the individuals, but they must provide personal assistance for an
individual who cannot manage personal care needs including eating during an
Individualized Skills and Socialization activity. An Individualized Skills and Socialization
provider must also be able to provide assistance with medications and the performance
of tasks delegated by a registered nurse.
Q7: Is there going to be an open enrollment period for ISS with times of the year
that are closed, or is it an open enrollment?
A7• An individual in the HCS, TxHmL, and DBMD Program can add Individualized Skills
and Socialization to their IPC at any point during the plan year. It is the individual’s or
their LAR’s choice if they would like to receive individualized skills and socialization.
• Any provider who is interested in delivering Individualized Skills and Socialization
services must obtain a Day Activity Health Services or DAHS – Individualized Skills
and Socialization service category license. The provider may apply at any time once
the online licensure portal (TULIP) is operational. HHSC anticipates that the license
application process will be available late November or December.
Q8: Are staffing ratios minimum or maximum? Will providers be reimbursed if
they go over the ratio?
A8: The staffing ratios described in the rule indicate that they are “no higher than” i.e.,
they describe the maximum ratio of individuals to service providers of Individualized
Skills and Socialization. To receive reimbursement and avoid recoupment of funds,
Individualized Skills and Socialization services (on-site, off-site, or in-home) must be
provided in accordance with the HCS, TxHmL, or DBMD Program rules.
Q9: Will ISS providers be required to have RNs as part of staff now that
medication management is part of the program? Additionally, our day hab does
not currently enroll individuals that need help with toileting or feeding needs,
will the program require that we do enroll these LONs individuals?
A9: If an individual receiving Individualized Skills and Socialization needs assistance
with medication or other nursing tasks, the HCS program provider’s nurse must ensure
the Individualized Skills and Socialization service providers are delegated/trained to
deliver the service. Individualized Skills and Socialization providers like day habilitation
providers can refuse to accept a person for services.
Q10: Is there any guidance regarding scheduling? For example, is the service
only Monday-Friday, etc.
A10: There is not a requirement for how many hours per day an Individualized Skills
and Socialization provider needs to provide services. There is a service limit for the
combined total of on-site, off-site, and in-home Individualized Skills and Socialization for
HCS and TxHmL of 1560 hours during an IPC year, six hours per calendar day, and five
days per calendar week.
Q11: Does an HCS, TxHmL or DBMD provider have to apply to be licensed as ISS
provider?
A11: An active day habilitation site could choose not to participate in Individualized Skills and
Socialization and not apply for a license. They would no longer be able to provide day
habilitation to individuals in HCS, TxHmL, and DBMD after March 1, 2023, since day hab will
no longer be a service at that point. Any provider who wishes to deliver Individualized Skills
and Socialization services will be required to have a Day Activity and Health Services –
Individualized Skills and Socialization license. A provider must obtain a temporary license
prior to delivering Individualized Skills and Socialization services and may choose to do so at
any time once the licensing system is available. HHSC Long-term Care Regulatory will issue a
provider a final license after conducting an on-site visit that results in final approval of the
license.
Q12: In the examples of ratios given, there was not an example that included an ICF
client. What are the expectations when mixing ICF clients with waiver clients?
A12: If a person is not in the TxHmL, HCS, or DBMD Program and is receiving services by a
staff member who is also providing on-site Individualized Skills and Socialization to an
individual in the DBMD Program or off-site to an individual in the HCS, TxHmL, and DBMD
Program, the appropriate HCS, TxHmL, and DBMD staffing ratio must be applied, and that
individual must be included in the staffing ratio.
Q13: If someone’s PDP says they need XX hours in the community, but we do
not have the manpower, are we still able to work with the client?
A13: Waiver providers can engage the Individualized Skills and Socialization
providers in the development of the implementation plan by identifying free or low-
cost activities (affordable by the individual) the Individualized Skills and Socialization
providers can offer within their community and match well with the individual’s
interests. Off-site Individualized Skills and Socialization is provided in a community
setting chosen by the individual from among available community setting options.
Community settings are settings accessible to the general public within an
individual’s community.
Q14: Day hab allowed for 5-hour minimum days, so now under ISS is it going
to be required to be 6 direct services timer?
A14: The service limit for the combined total of on-site, off-site, and in-home
Individualized Skills and Socialization for HCS and TxHmL is:
(1) 1560 hours during an IPC year;
(2) six hours per calendar day; and
(3) five days per calendar week.
Individuals can receive less than six hours per calendar day.
Q15: If the individual/LAR choses not to utilize the ISS program, will
they still be able to receive funding from TxHmL/HCS?
A15: The individual or LAR can choose to receive in-home Individualized
Skills and Socialization if the individual meets the policy for in-home
delivery. Individuals living in three and four person residences would need
to participate in employment or day activity with natural supports if the
LAR or individual does not choose to receive individualized skills and
socialization and does not meet the policy guidance for in-home
individualized skills and socialization. Access to HCS and TxHmL waiver
services is not dependent upon receiving individualized skills and
socialization.
Q16: Can we have a combination of HCS waivers and private pay? Does private
pay also need to be in the community?
A16: Individualized Skills and Socialization providers will have a choice about how to
conduct business. They will be allowed to accept all payor sources, or they may choose
to accept only waiver (HCBS) or non-waiver. The HCBS settings regulations do not apply
to ICF/IID, private pay or general revenue and therefore, day habilitation can continue
to be provided without changing the service to individualized skills and socialization;
however, if a provider wants to serve individuals in the waiver programs, the provider
must do so as a licensed individualized skills and socialization provider after March 1,
2023. Individualized skills and socialization has both on-site and off-site services that
must be offered to individuals in the waivers.
Q17: Will ISS provided in the client’s home require EVV verification for HCS and
TxHmL funded clients? If the client lives in a group home or a Host
Home/Companion Care home, will the EVV verification be required?
A17: In-home Individualized Skills and Socialization provided in the individual’s own
home or family home will require the use of EVV verification, similar to in-home day
habilitation today. If the individual lives in a 3-person or 4-person residence, or a host
home/companion care residence, EVV verification will not be required.
Q18: Will we need a separate license for each day hab our individuals
attend including any families that provided in-home day hab due to
their LON and medical need?
A18: Each physical location that provides on and off-site Individualized Skills
and Socialization services will require its own license and application process.
In-home services will not require a license.
Q19: Can you give a few examples of offsite locations?
A19:Visits to the museums, libraries and parks are examples of off-site
Individualized Skills and Socialization activities if they are chosen by the
individual, integrate the individual into the community, and promote the
development of skills and behavior that support independence and personal
choice.
For further questions, contact:
HCSPolicy@hhs.texas.gov
TxHmLPolicy@hhs.texas.gov
LTCRPolicy@hhs.texas.gov
HHSC will conduct a public hearing on the proposed HCS, TxHmL and DBMD ISS program rules on September 7, 2022 from 8:00 am. until Noon. To register for the virtual hearing, go to: https://attendee.gotowebinar.com/register/927810115195515152
