What is ISS in Texas?

What is Individualized Skills and Socialization?

ISS is a Texas Medicaid waiver service that assists an individual to acquire the skills needed to live in, integrate into, and take part successfully in the community. It is offered in the HCS, TxHmL, and Deaf Blind with Multiple Disabilities (DBMD) waiver programs.

HHSC created ISS to meet federal rules. In 2014, the Centers for Medicare & Medicaid Services (CMS) issued regulations on the settings where Medicaid home and community-based services are provided. To comply, HHSC replaced the old day service in these waivers with ISS, which HHSC calls a new, more integrated service.

ISS billable activities include working in person with an individual on objectives from their plan: self-help and adaptive skills, independence, socialization, community participation, volunteering, and employment goals. ISS staff can also help with daily living tasks during an activity, and, as an RN's assessment allows, with medications and RN-delegated tasks.

When did ISS start in Texas?

The Texas ISS rules took effect on January 1, 2023, and the old day service stopped being an allowable service in the HCS, TxHmL, and DBMD waivers effective March 1, 2023. HHSC expected all ISS providers to begin off-site ISS by March 17, 2024.

Programs can still offer a day program to people outside these waivers. HHSC says providers may keep serving people through other funding, including private pay, without an ISS license, as long as they are not serving individuals in the HCS, TxHmL, or DBMD waivers.

What is the difference between on-site, off-site, and in-home ISS?

On-site ISS happens in a building the ISS provider owns or leases. Off-site ISS happens in a community setting the individual chooses, such as a library, store, fair, or park. In-home ISS happens in the individual's residence, only for individuals who meet specific criteria.

Off-site ISS includes the ride from an on-site location to the community and between community locations, so that transportation time is billed as off-site ISS. It cannot be provided in a building where on-site ISS is provided, and HHSC treats another building on the same property as part of the on-site facility.

In-home ISS requires documentation of a medical condition or behavioral issue that justifies it, or an individual who is 55 or older. It does not have to be provided by a licensed ISS provider, but a host home/companion care provider cannot be the individual's in-home ISS provider.

How much time an individual spends on-site and off-site varies by person, based on the goals the service planning team sets. The ISS provider develops activities that support those goals. HHSC has said there is no option to provide on-site ISS only.

Who can provide ISS in Texas?

On-site and off-site ISS must be provided by a licensed ISS provider. HHSC licenses these providers as Day Activity Health Services (DAHS) with ISS, or DAHS ISS Only, through the Texas Unified Licensure Information Portal (TULIP).

The licensing rules are in 26 TAC Chapter 559, Subchapter H. The program rules are in 26 TAC Chapter 263, Subchapter L for HCS, Chapter 262, Subchapter J for TxHmL, and Chapter 260, Subchapter I for DBMD. HCS providers follow both sets.

An HCS or TxHmL provider must make on-site and off-site ISS available to its individuals. It can get its own ISS license, or it can subcontract with a licensed ISS provider. Only providers that want to deliver ISS directly need the license.

HHSC does not assign individuals to ISS providers. Each individual chooses among ISS providers in their area that can meet their needs, so one licensed ISS program can serve individuals placed by several residential providers.

How is ISS billed and what are the limits?

In HCS, on-site and off-site ISS are billed in one-hour units, and a claim may include a quarter, half, or three-quarter unit. Combined with in-home ISS and employment readiness, a claim may not exceed 6 units a day, 30 units a week, or 1,560 units per IPC year.

The IPC does not split on-site, off-site, and in-home ISS. It shows total ISS units for the IPC year, and transportation is included in ISS, so it is not added as a separate service on the IPC.

HHSC's ISS FAQ ties electronic visit verification (EVV) to in-home ISS provided in an own home or family home. EVV claims matching is not required for in-home ISS in a three-person or four-person residence or a host home.

What documentation does ISS require?

On-site and off-site ISS are documented on HHSC Form 8615, the HCS and TxHmL On-site and Off-site ISS Service Delivery Log, and in-home ISS on Form 8616. Each log must be completed within 14 calendar days after the service.

For on-site ISS, HCS billing rules require the exact start and end time of each service event for each day, the objectives from the individual's implementation plan that staff are working on, and the name and signature of a staff member who provided the service.

Off-site ISS needs all of that plus the individual's level of need, the staffing ratio required by rule, the number of individuals and other people in the group, and a description of each community location. Form 8615 has fields for the ratio, the community locations visited, special or unusual occurrences, and staff initials next to each area where they helped the person. A new Form 8615 is needed if there are more than two service events in one day.

The provider keeps a copy in the individual's record. HHSC says logs can be handwritten or electronic, as long as they are legible.

• Exact time in and time out for each service event
• Implementation plan objectives worked on
• Staff name and signature
• Off-site: level of need, staffing ratio, group size, and each location
• Any special or unusual occurrence
• Completed within 14 calendar days

How does Sereniq support ISS programs?

Sereniq runs the ISS day on a four-tap attendance board: van in, trip out, everyone back, day done. The times on the board fill the weekly service log, which prints as a one-to-one Form 8615 facsimile.

Trips carry the staff and group counts, so the ratio is written onto each off-site block. At month end, Sereniq builds a statement and invoice for each residential agency that places individuals in the program. It does not submit Medicaid claims.

A standalone ISS program gets its own ISS account, and an HCS provider that also runs ISS adds it to the same account.