26 Tex. Admin. Code § 259.65 - Development of an Enrollment IPC

(a) No later than 30 calendar days after the date a DSA notifies an individual's CMA of HHSC's determination that the individual meets the LOC VIII criteria, as described in §259.61(k) of this division (relating to Process for Enrollment of an Individual), the CMA must ensure that the individual's case manager:

(1) convenes a service planning team meeting in person or by videoconferencing in which the service planning team:

(A) reviews the HHSC CLASS/DBMD Nursing Assessment form completed by an RN as described in §259.61(h)(3) of this division;

(B) addresses any information included in Addendum E of the HHSC CLASS/DBMD Nursing Assessment form, Recommendations/Coordination of Care, to ensure the individual's needs are met;

(C) documents on the HHSC CLASS/DBMD Coordination of Care form how the information in Addendum E of the HHSC CLASS/DBMD Nursing Assessment form was addressed;

(D) develops a PAS/HAB plan based on review of the information obtained from assessments conducted and observations made by a DSA as required by §259.61(h)(2) and (3) of this division;

(E) develops a proposed enrollment IPC that:

(i) documents each CLASS Program service and CFC service, other than CFC support management, to be provided to an individual;

(ii) specifies the number of units of each CLASS Program service and CFC service, other than CFC support management, to be provided to an individual;

(iii) for each CLASS Program service:

(I) is within the service limit described in §259.73 of this division (relating to Service Limits);

(II) if an adaptive aid, meets the requirements in Subchapter F, Division 1, of this chapter (relating to Adaptive Aids); and

(III) if a minor home modification, meets the requirements in Subchapter F, Division 2, of this chapter (relating to Minor Home Modifications);

(iv) for CFC ERS, meets the requirements in Subchapter F, Division 3, of this chapter (relating to CFC ERS);

(v) identifies if an individual will receive CFC support management;

(vi) describes any other service or support to be provided to the individual through sources other than CLASS Program services or CFC services;

(vii) if the proposed enrollment IPC includes nursing or CFC PAS/HAB, identifies whether the service is critical to the individual's health and safety, as required by § 259.89(a)(2) of this subchapter (relating to Service Backup Plans);

(viii) if the individual will receive TAS, the TAS and the monetary amount authorized by HHSC; and

(ix) if the individual chooses to receive services through the CDS option, identifies:

(I) the name of the individual's FMSA; and

(II) the type and estimated units of each CLASS Program service and CFC service provided through the CDS option;

(F) develops an IPP for each CLASS Program service and CFC service listed on the proposed enrollment IPC, other than CFC support management, as required by §259.67 of this division (relating to Development of IPPs);

(G) develops an HHSC IPP Addendum form;

(H) if the proposed enrollment IPC identifies nursing or CFC PAS/HAB as critical, develops a service backup plan for the service in accordance with § 259.89 of this subchapter; and

(I) if transportation as a habilitation activity or as an adaptive aid is included on the proposed enrollment IPC, develops an individual transportation plan; and

(2) if an individual may need cognitive rehabilitation therapy, assists the individual in obtaining an assessment as required by § 259.311(h) of this chapter (relating to CMA Service Delivery).

(b) A case manager must ensure that each CLASS Program service and CFC service on a proposed enrollment IPC, other than CFC support management:

(1) is necessary to protect an individual's health and welfare in the community;

(2) addresses an individual's related condition;

(3) is not available to an individual through sources other than CLASS Program services or CFC services, including the Medicaid State Plan, other governmental programs, private insurance, or the individual's natural supports;

(4) is the most appropriate type and amount of CLASS Program service and CFC service to meet an individual's needs; and

(5) is cost effective.

(c) If an individual or LAR, case manager, and DSA agree on the type and amount of services to be included in a proposed enrollment IPC, a case manager must:

(1) if the service planning team meeting required by subsection (a)(1) of this section is conducted in person, ensure that during the service planning team meeting the proposed enrollment IPC is reviewed, signed as evidence of agreement, and dated by:

(A) the individual or LAR;

(B) the case manager; and

(C) the DSA; or

(2) if the service planning team meeting required by subsection (a)(1) of this section is conducted by videoconferencing, ensure that the proposed enrollment IPC is reviewed, signed as evidence of agreement, and dated by the individual or LAR and the DSA electronically, by fax, or by United States mail; and

(3) no later than 30 calendar days before the effective date of the proposed enrollment IPC as determined by the service planning team:

(A) submit to HHSC for its review:

(i) the proposed enrollment IPC;

(ii) the enrollment IPPs;

(iii) the HHSC IPP Addendum form;

(iv) the PAS/HAB plan;

(v) the completed HHSC CLASS/DBMD Nursing Assessment form provided by the DSA in accordance with §259.61(i)(3) of this division;

(vi) the ID/RC Assessment authorized by HHSC;

(vii) the HHSC Non-Waiver Services form;

(viii) the HHSC Verification of Freedom of Choice form;

(ix) Choice List for the CLASS Program;

(x) the individual transportation plan, if required by subsection (a)(1)(I) of this section;

(xi) an HHSC Request for Adaptive Aids, Medical Supplies, Minor Home Modifications or Dental Services/Sedation form, if required by;

(I) § 259.255 of this chapter (relating to Requirements for Authorization to Purchase an Adaptive Aid Costing Less Than $500);

(II) § 259.257 of this chapter (relating to Requirements for Authorization to Purchase an Adaptive Aid Costing $500 or More);

(III) § 259.275 of this chapter (relating to Requirements for Authorization to Purchase a Minor Home Modification); and

(IV) § 259.361 of this chapter (relating to Respite and Dental Treatment);

(xii) an HHSC Specifications for Adaptive Aids/Medical Supplies/Minor Home Modifications form, if required by:

(I) § 259.257 of this chapter; and

(II) § 259.275 of this chapter;

(xiii) letters of denial from non-waiver resources, if any;

(xiv) if the proposed enrollment IPC includes TAS, the HHSC Transition Assistance Services Assessment and Authorization form; and

(xv) if the proposed enrollment IPC includes a skilled or a specialized therapy, the HHSC Therapy Justifications - Attachment to IPP form;

(B) send the DSA a copy of:

(i) the proposed enrollment IPC;

(ii) the enrollment IPPs;

(iii) the HHSC IPP Addendum form;

(iv) the PAS/HAB plan;

(v) a service backup plan, if required by subsection (a)(1)(H) of this section; and

(vi) the individual transportation plan, if required by subsection (a)(1)(I) of this section; and

(C) if the proposed enrollment IPC includes a service the individual chooses to receive through the CDS option, send the FMSA a copy of:

(i) the proposed enrollment IPC;

(ii) the IPPs;

(iii) the HHSC IPP Addendum form;

(iv) the PAS/HAB plan;

(v) a service backup plan, if is required by subsection (a)(1)(H) of this section; and

(vi) the individual transportation plan, if required by subsection (a)(1)(I) of this section.

(d) If an individual or LAR requests a CLASS Program service or CFC service that a case manager or DSA has determined does not meet the criteria described in subsection (b) of this section, does not meet the requirements described in Subchapter F of this chapter, or exceeds a service limit described in §259.73 of this division, a CMA must:

(1) in accordance with the Community Living Assistance and Support Services Provider Manual, send the individual or LAR a written notice of the denial of the requested CLASS Program service or CFC service, copying the DSA and FMSA;

(2) no later than 30 calendar days before the effective date of the proposed enrollment IPC as determined by the service planning team, submit to HHSC for its review:

(A) the proposed enrollment IPC that:

(i) includes the type and amount of CLASS Program services or CFC services in dispute and not in dispute; and

(ii) is signed and dated by:

(I) the individual or LAR;

(II) the case manager; and

(III) the DSA;

(B) the IPPs;

(C) the HHSC IPP Addendum form;

(D) the PAS/HAB plan; and

(E) the individual transportation plan, if required by subsection (a)(1)(I) of this section; and

(3) if the individual will receive a service through the CDS option, send the FMSA a copy of:

(A) the proposed enrollment IPC;

(B) the IPPs;

(C) the PAS/HAB plan;

(D) a service backup plan, if required by subsection (a)(1)(H) of this section; and

(E) the individual transportation plan, if required by subsection (a)(1)(I) of this section.

(e) HHSC reviews a proposed enrollment IPC in accordance with §259.69 of this division (relating to HHSC's Review of a Proposed Enrollment IPC).

(f) The process by which HHSC denies an individual's request for enrollment or denies a CLASS Program service or CFC service, based on HHSC's review of a proposed enrollment IPC, is described in §259.69(d) - (f) of this division.

(g) The effective date of an enrollment IPC is the effective date proposed by the service planning team, unless HHSC modifies the effective date.

(h) An enrollment IPC is effective for an IPC period.

Notes

26 Tex. Admin. Code § 259.65

Adopted by Texas Register, Volume 48, Number 04, January 27, 2023, TexReg 0376, eff. 1/30/2023