TX HHS Form 1047. Request for HCS Targeted NF Diversion Slot

The TX HHS Form 1047, Request for HCS Targeted NF Diversion Slot, helps resolve the issue of individuals at imminent risk of long-term stays in nursing facilities. This form is used by Local Intellectual and Developmental Disability Authorities (LIDDA) to request targeted diversion slots for individuals with intellectual or developmental disabilities who meet specific criteria.

The form requires information about the individual's name, Medicaid number, date of birth, and current waiver services received. It also outlines the LIDDA's determination that the person meets certain criteria, including imminent risk of a long-term stay in an NF, medical necessity, and diagnostic eligibility for Home and Community-based Services (HCS). The form must be completed by the LIDDA and supporting documentation scanned and sent to [email protected] with the subject line "Request for HCS Targeted NF Diversion Slot."

• The individual is at imminent risk of a long-term stay in an NF.
• The person has an intellectual or developmental disability and is appropriate for community placement.
• The Long-Term Care online portal indicates the person meets medical necessity.