This guidance defines expectations and processes related to the resumption of Medicaid managed care organization (MCO) in-person assessments, reassessments, and service coordination activities. Beginning in March 2020, the Texas Health and Human Services Commission (HHSC) suspended the requirement that Medicaid MCOs conduct member assessments and service coordination visits in-person due to the COVID-19 public health emergency. HHSC would like to inform nursing facility (NF) and assisted living facility (ALF) providers that MCOs are permitted to resume in-person assessments and service coordination visits, effective no later than September 1, 2021. MCOs may resume these activities earlier than September 1, 2021, based on their ability to do so. While no direct action is required by providers based on this guidance, NFs and ALFs should anticipate and adjust their protocols to allow MCOs to begin visiting residents in-person, as appropriate.
- If an in-person encounter is the stated preference or necessity of member residing in a NF or ALF, or their legally authorized representative (LAR), MCOs may complete all or part of the assessment or service coordination visit with an in-person encounter. Optionally, a portion of the assessment or service coordination visit could be conducted via telephone or telehealth and completed in person. MCOs are also permitted to conduct routine service coordination visits in person when requested or required to ensure the health and safety of the member receiving services.
- In conducting in-person visits and assessments, MCOs must comply with current COVID-19 orders issued by the Office of the Governor. Refer to CDC and DSHS websites for the most up-to-date guidance on infection control measures, and adhere to the expanded visitation policies as directed by Long-term Care Regulation.
- The determination of how the MCO will complete the in-person portion of an assessment or service coordination visit is based on the judgement of the service coordinator in collaboration with the MCO medical director, NF staff, ALF staff, and the member or LAR. The variables that MCOs will consider when determining how an in-person visit or assessment will be conducted include:
- The prevalence of community transmission and COVID-19 rates in the member’s area
- The health status of the member, including changes in health status that necessitate in-person visualization of the member and member’s environment
- The health status of the service coordinator
- The service coordinator’s familiarity with the member’s health status, environment, and support needs
- The availability of telehealth options that could take the place of an in-person visit
- The MCO service coordinator’s access to appropriate personal protective equipment (PPE)
- For members residing in NFs and ALFs, the facility’s current protocols that may be in place to protect the health of their residents
Telehealth Assessments and Service Coordination Visits
Parts of the functional assessments require visualization of the member and member’s environment. Telehealth (audio + visual) should be the primary modality to conduct assessments during the continued COVID-19 pandemic if in-person is not feasible. Telehealth should also be the primary modality for service coordination visits if in-person is not feasible. This modality allows MCOs to decrease the potential opportunity for disease transmission while ensuring that assessments are clinically accurate, and members have access to medically necessary services.
Ideally, assessments and required in-person service coordination visits are conducted in person or via telehealth. If in-person service coordination visits or assessments cannot be completed via telehealth or in person, the service coordination contact or assessment may be completed telephonically (audio only) as a last resort, and in compliance with applicable HIPAA regulations.