| (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 CFR §§441.535 - 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.
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