1 Tex. Admin. Code § 354.1363 - Assessment

(a) Level of care (LOC) assessment.

(1) To determine nursing facility and hospital LOC, HHSC uses the Medical Necessity/Level of Care (MN/LOC) assessment. MN is the determination that an individual requires the services (supervision, assessment, planning, and intervention) of licensed nurses in an institutional setting to carry out a physician's planned regimen for total care.

(2) To determine ICF/IID LOC, HHSC uses the Intellectual Disability/Related Condition assessment (ID/RC). The ID/RC assessment includes all factors needed to determine an LOC: diagnostic information that includes age of onset of the qualifying conditions, names of qualifying conditions, the appropriate International Classification of Diseases codes, results of standardized intelligence testing, and the adaptive behavior level as determined by an approved adaptive behavior assessment tool.

(3) To determine psychiatric inpatient LOC for individuals under age 21, and institution for mental disease LOC for individuals age 65 and over, the Child and Adolescent Needs and Strengths assessment (CANS) or Adult Needs and Strengths assessment (ANSA) is completed and entered into a State system which has an automated clinical and diagnostic tool that helps determine an individual's LOC. The system uses CANS or ANSA data to determine whether an individual meets Medicaid inpatient psychiatric admission criteria.

(b) Functional needs assessment. Assessments for CFC services are conducted by existing assessors who are determined to be qualified by the State in a state plan or LTSS program already approved by CMS. Assessments are provided without regard to an individual's age or disability. The functional needs assessment and person-centered service plan development process comply with the requirements set forth in 42 C.F.R. 441.535 - 42 C.F.R. 441.540.

(1) CFC functional needs assessments are conducted initially and at least annually, unless a change in condition or health status requires reassessment at an earlier date, or the individual requests a reassessment. The assessments are conducted face-to-face and include an assessment of an individual's functional needs, strengths, preferences, and goals for the services and supports provided under CFC.

(2) Individuals are assessed for functional needs by a qualified provider, at a time and location convenient for the individual. The assessment is conducted as part of a person-centered planning process with the individual and anyone else chosen by the individual. Initially and at least annually, in partnership, the assessor, individual, and a service planning team comprised of members chosen by the individual develop a recommended service plan for review and consideration by HHSC or the appropriate MCO.

(3) Qualified assessors of functional needs include LIDDAs and mental health authorities, MCO service coordinators or service managers, DSHS case workers, direct service agencies, and case management agencies.

(c) Requirements on entities conducting the assessments. A person or entity conducting the functional needs assessment or facilitating the person-centered service plan for the individual must not:

(1) be related by blood or marriage to the individual, or to any paid caregiver of the individual;

(2) be financially responsible for the individual;

(3) be empowered to make financial or health-related decisions on behalf of the individual;

(4) benefit financially from assessing the individual's needs or providing CFC services to the individual; or

(5) be a provider of CFC services for the individual or have an interest in or be employed by a provider of CFC services for the individual, unless:

(A) HHSC determines that the provider is the only willing and qualified entity able to perform assessments of functional need and develop person-centered service plans in a geographic area; and

(B) the provider adheres to a conflict of interest policy developed by HHSC.

Notes

1 Tex. Admin. Code § 354.1363

Adopted by Texas Register, Volume 40, Number 21, May 22, 2015, TexReg 2746, eff. 6/1/2015; Amended by Texas Register, Volume 41, Number 22, May 27, 2016, TexReg 3905, eff. 6/2/2016