In this report, services and housing arrangements for people with mental retardation and related conditions (MR/RC) within the State of Texas are examined. Below, is a list of key terms used commonly throughout this report, as well as their meaning/definition.
Federal Definition of Developmental Disabilities
The U.S. Developmental Disabilities Assistance and Bill of Rights Act of 2000 (P.L. 106-402) reads as follows:
- In general, the term “developmental disability” means a severe, chronic disability of an individual that:
- Is attributable to a mental or physical impairment or a combination of mental and physical impairments
- Is manifested before the individual attains age 22
- Is likely to continue indefinitely
- Results in substantial functional limitations in three or more of the following areas of major life activity: (a) self care, (b) receptive and expressive language, (c) learning, (d) mobility, (e) self-direction, (f) capacity for independent living, and (g) economic self-sufficiency
- Reflects the individual’s need for a combination and sequence of special, interdisciplinary, or generic services, individualized supports, or other forms of assistance that are of lifelong or extended duration and are individually planned and coordinated.
- Infants and young children: An individual from birth to age nine, inclusive, who has a substantial delay or specific congenital or acquired condition, may be considered to have a developmental disability without meeting three or more of the criteria described in clauses (i) through (v) of subparagraph (A) if the individual, without services and supports, has a high probability of meeting these criteria later in life.
It is worth noting that states do not have to use the federal definition of developmental disabilities and many have their own variation of the definition.
Mental Retardation and Related Conditions
DADS defines Mental Retardation and Related Conditions as follows:
Mental Retardation 1 is defined by 25 Texas Administrative Code (TAC) §415.153 as:
Consistent with THSC, §591.033, significantly sub-average general intellectual functioning existing concurrently with deficits in adaptive behavior and manifested during the developmental period.
Related Condition is defined by 25 TAC §415.153 as: As defined in the Code of Federal Regulations (CFR), Title 42, 435.1009, a severe and chronic disability that:
- Is attributable to:
- Cerebral palsy or epilepsy or
- Any other condition, other than mental illness, found to be closely related to mental retardation because the condition results in impairment of general intellectual functioning or adaptive behavior similar to that of persons with mental retardation, and requires treatment or services similar to those required for persons with mental retardation
- Is manifested before the person reaches the age of 22 and
- Is likely to continue indefinitely; and
- Results in substantial functional limitation in three or more of the following areas of major life activity:
- Understanding and use of language
- Self direction and
- Capacity for independent living
State schools/centers are large state-run facilities for people with intellectual disabilities. These facilities are Intermediate Care Facilities for the Mentally Retarded (described below) and provide round-the-clock care to facility residents. These settings are typically referred to as “very large” settings, housing 75 to 620 individuals in Texas. Nationally, these facilities are referred to as “large state-run institutions.” Texas currently has 13 state schools/centers serving individuals with intellectual disabilities. The Office of the State Auditor concluded in its July 2008 report that Texas has the nation’s largest population of individuals receiving mental retardation services in large state-run institutions.
Intermediate Care Facility for the Mentally Retarded (ICF/MR)
The designation of ICF/MR refers to a type of residential setting that is supported through the federal Medicaid program and jointly funded through state and federal match. The ICF/MR program provides highly-regulated residential care and treatment for people with mental retardation or severe related conditions. In Texas, ICFs/MR range from smaller residential facilities for 1 to 6 individuals up to large facilities housing 16 or more individuals, and in many cases provide 24 hour care. Many of the small ICFs/MR are privately owned and were in operation before HCBS waiver (described below) services became an alternative funding option in Texas. There are 60 medium sized (7-15 bed) ICFs/MR in the state along with 19 larger private ICFs/MR.
Home and Community-Based Services (HCBS) Waiver
The University of Minnesota, Research and Training Center on Community Living defines home and community-based services as follows:
“Section 2176 of the Omnibus Budget Reconciliation Act of 1981 (P.L. 97-35), passed on August 13, 1981, granted the Secretary of Health and Human Services the authority to waive certain existing Medicaid requirements and allow states to finance ‘non-institutional’ services for Medicaid-eligible individuals. The Medicaid Home and Community-Based Services (HCBS) waiver program was designed to provide non-institutional, community services to people who are aged, blind, disabled, or who have I/DD (intellectual or developmental disabilities) and who, in the absence of alternative non-institutional services, would remain in or would be at a risk of being placed in a Medicaid facility (i.e., a Nursing Facility or an ICF/MR). Final regulations were published in March 1985 and since then a number of new regulations and interpretations have been developed, although none have changed the fundamental premise of the program, that of using community services to reduce the need for institutional services.
A wide variety of non-institutional services are provided in state HCBS programs, most frequently these include service coordination/case management, in-home support, vocational and day habilitation services, and respite care. Although not allowed to use HCBS reimbursement to pay for room and board, all states provide residential support services under categories such as personal care, residential habilitation, and in-home supports.2”
Texas Home and Community-Based Services (HCBS) Waivers
Community Based Alternatives (CBA)
The CBA waiver serves older adults and adults with disabilities as a cost-effective community alternative to living in a nursing home. DADS provides case management services to participants in this waiver program. Services available through this waiver include: adaptive aids and medical supplies, adult foster care, assisted living residential care services, consumer directed services, emergency response services, home delivered meals, minor home modifications, nursing services, occupational and physical therapy, personal assistance services, prescription drugs (if not covered through Medicare), respite care, and speech and/or language pathology services. While a handful of older individuals with MR/RC are involved in this program, the primary target population consists of elderly and non-elderly individuals with physical disabilities.
Community Living Assistance and Support Services (CLASS)
Serves people with mental retardation or related conditions as a cost-effective community alternative to placement in an intermediate care facility. Services available through this waiver include: adaptive aids and medical supplies, case management, the Consumer Directed Services (CDS) option, habilitation, minor home modifications, nursing services, occupational and physical therapy, prescription drugs (if not covered through Medicare), psychological services, respite care, specialized therapies, and speech pathology. The CLASS waiver does not provide habilitation services in community facilities with 24-hour care responsibilities and, as such, does not address the residential support needs of many individuals on the interest list for HCS waiver services. CLASS services are available in specific geographic catchment areas.
Deaf-Blind with Multiple Disabilities (DB-MD)
The DB-MD waiver serves individuals who are deaf and/or blind with multiple disabilities as a cost-effective alternative to institutional placement. The program focuses on increasing opportunities for consumers to communicate and interact with their environment. Clients can choose from among three options for residential support:
- live in their own home or apartment with support;
- live with a parent or guardian with support; or
- live in a group home with support.
Services available through this waiver include adaptive aids and medical supplies; assisted living (licensed up to six beds); behavior communication services; case management; chore provider; the Consumer Directed Services (CDS) option; day habilitation; dietary services; environmental accessibility/minor home modifications; intervener; nursing services; occupational and physical therapy; orientation and mobility; prescription drugs (if not covered through Medicare); residential habilitation; respite care; speech, hearing, and language therapy; and transition assistance services.
Home and Community-based Services Program (HCS)
Serves people with mental retardation as a cost-effective community alternative to placement in an intermediate care facility. HCS serves individuals who are living with their family, in their own home, or in other community settings, such as small group homes. Services available through this waiver include case management, adaptive aids, minor home modifications, counseling and therapies (includes audiology, speech/language pathology, occupational therapy, physical therapy, dietary services, social work, and psychology), dental treatment, nursing, residential assistance (e.g., supported home living, foster/companion care, supervised living, residential support), respite, day habilitation and supported employment.
Integrated Care Management (ICM) 1915(c) waiver
This program is a non-capitated primary care case management model of Medicaid managed care. ICM is available only in the Dallas and Tarrant county service areas. ICM Program participation is mandatory for individuals who are 21 years of age and older who receive Supplemental Security Income (SSI) or are SSI-related, receive SSI and are dually eligible for Medicaid and Medicare, and participate in Community-Based Alternatives (CBA) and who wish to receive the same services they now receive in CBA. ICM is voluntary for SSI children under 21 years of age in the ICM Service Areas. Individuals in institutional settings and those in waiver programs other than CBA are excluded from the ICM Program.
ICM members will remain eligible for the full set of Medicaid benefits they currently receive. ICM members who are not dually eligible for Medicaid and Medicare are eligible to receive unlimited medically necessary prescriptions. They also will have access to an annual adult wellness check. ICM long-term services and supports (LTSS) include Primary Home Care (PHC) and Day Activity and Health Services (DAHS). ICM members may also be eligible for the ICM 1915(c) waiver services. The ICM 1915(c) waiver offers the same array of services as the CBA waiver.
Medically Dependent Children Program (MDCP)
This waiver provides services to support families caring for children who are medically dependent and to encourage de-institutionalization of children in nursing facilities. DADS’ employees provide case management services to MDCP eligible children. Services available through this waiver include: respite care, adjunct support services, adaptive aids, minor home modifications, and assistance with nursing facility to community transition.
STAR+PLUS 1915(b)(c) waiver
STAR+PLUS is a Texas Medicaid program that provides health care as well as acute and long-term services and support through a managed care system. It is administered by the Texas Health and Human Services Commission (HHSC). Services are provided through health maintenance organizations (HMOs), which are health plans operating under contract with DADS. Through these health plans the STAR+PLUS program combines traditional health care (such as doctor visits) and long-term services and support, such as providing help in your home with daily activities, home modifications, respite care (short-term supervision) and personal assistance. People with MR/RC who require ICF/MR level of care are not eligible to participate in this program.
Texas Home Living (TxHmL) waiver
This is a cost-effective community alternative to placement in an intermediate-care facility that provides selected essential services and supports to children and adults with mental retardation who live in their family homes or their own homes. Services available through this waiver include adaptive aids, minor home modifications, specialized therapies (audiology, speech/language pathology, occupational therapy, physical therapy, and dietary services), behavioral support, dental treatment, nursing, community support, respite, day habilitation, employment assistance and supported employment. Unlike the HCS waiver program, the TxHmL program operates under a per participant spending cap, which was $10,000 per year in 2007.
- Texas Health and Human Services Department, The Long-Term Care Plan for People with Mental Retardation and Related Conditions Fiscal Years 2006 — 2007. Retrieved September 2008. ↩
- Prouty, R., Smith, G. and Lakin, K.C. (eds.) (2007). Residential Services for People with Developmental Disabilities: Status and Trends Through 2006. Page 92. Minneapolis: University of Minnesota, Research and Training Center on Community Living. ↩