TX HHS Form 1046. Request for HCS Adult NF Transition Slot

Form 1046 is a standardized document used by Local Intellectual and Developmental Disability Authorities (LIDDAs) in Texas to request a Home and Community-based Services (HCS) Adult Nursing Facility (NF) Transition Slot for an eligible individual. The form is an essential part of the transition process for adults with intellectual or developmental disabilities who currently reside in a nursing facility but wish to move to a community-based setting. It provides HHSC with the key information required to determine eligibility and allocate available transition slots.

Purpose of the Form

The primary purpose of Form 1046 is to formally notify the Texas Health and Human Services Commission (HHSC) that a person meets the criteria for transition from a nursing facility to HCS services. The form is submitted only by LIDDAs and is used in cases where an individual is at least 21 years old, lives in an NF, and expresses a desire to relocate into the community with the support of the HCS waiver program.

Who Uses This Form

Form 1046 is completed exclusively by representatives of Local Intellectual and Developmental Disability Authorities. These representatives evaluate the individual's circumstances, verify eligibility, and coordinate the transition request. The form may involve information provided by the person, their legally authorized representative, and the nursing facility.

When the Form Is Required

A LIDDA submits Form 1046 when:

• The individual is an adult aged 21 or older.
• They currently reside in a nursing facility.
• They wish to move to a community environment with HCS support.
• At least 30 days have passed since nursing facility admission when the admission was for rehabilitative purposes.

The form is not used for children, individuals who do not desire community placement, or those receiving HCS transition support through other processes.

Form Structure and Required Information

1. LIDDA Information

This section identifies the LIDDA submitting the request. It includes:

• Date of request
• LIDDA name and component code
• Name and contact information of the LIDDA Diversion Coordinator
• Email address and phone number for follow-up communication

2. Person's Information

Detailed personal and eligibility information is provided to allow HHSC to verify the individual's status. This includes:

• Person’s full name and CARE ID
• Residential address and county of residence
• Name of legally authorized representative, if applicable
• Date of nursing facility admission
• Medicaid number
• Date of birth
• Date of PASRR Evaluation (PE)

3. Current Services

The form requires the LIDDA to indicate whether the person is currently enrolled in any Texas waiver programs. Options include:

• Texas Home Living (TxHmL)
• Community Living Assistance and Support Services (CLASS)
• Medically Dependent Children Program (MDCP)
• Deaf Blind with Multiple Disabilities (DBMD)
• STAR+PLUS Waiver
• Youth Empowerment Services (YES)
• None

4. Eligibility Criteria Confirmation

The LIDDA must certify that the individual meets all required criteria for requesting an HCS Adult NF Transition Slot:

• The person is at least 21 years old.
• They are currently residing in a nursing facility.
• They have expressed a desire to live in a community setting.
• More than 30 days have passed since admission if the stay was for rehabilitation.

5. Additional Comments

A section is provided for any relevant notes or clarifications that may assist HHSC in reviewing the request.

6. Submission Instructions

After the form is completed, it must be scanned along with all supporting documentation and sent via secure email to:

[email protected]

The email subject line must read: “Request for HCS Adult NF Transition Slot.”

7. HHSC Use Only

The final section is completed internally by HHSC staff and includes:

• Date and time the request was received
• Review status
• Recommendation outcome for the transition slot

Form Details

• Form Name: Request for HCS Adult NF Transition Slot
• Form Number: 1046
• Issued By: Texas Health and Human Services Commission (HHSC)
• Region: Texas
• Edition: January 2023