| (a) A program provider may request a level one enhanced
staffing rate for off-site individualized skills and socialization
described in §262.925(b) of this subchapter (relating to Program
Provider Reimbursement for On-Site, Off-Site, and In-Home Individualized
Skills and Socialization) for an individual with a LON 1 or LON 5
who receives off-site individualized skills and socialization from
the program provider.
(b) A program provider may request a level two enhanced
staffing rate for off-site individualized skills and socialization
described in §262.925(b) of this subchapter for an individual
with a LON 1, LON 5, LON 8, or LON 6 who receives off-site individualized
skills and socialization from the program provider.
(c) A service coordinator must request a level one
enhanced staffing rate for an individual with a LON 1 or LON 5 or
request a level two enhanced staffing rate for an individual with
a LON 1, LON 5, LON 8, or LON 6 for off-site individualized skills
and socialization described in §262.925(b) of this subchapter
for an individual who receives off-site individualized skills and
socialization through the CDS option if the CDS employer asks the
service coordinator to request the enhanced staffing rate.
(d) A program provider or service coordinator makes
the request described in subsections (a) - (c) of this section by
submitting the following documentation to HHSC:
(1) a completed HHSC Enhanced Staffing Rate Request
Form;
(2) the most recent ICAP scoring booklet;
(3) the most recent ID/RC Assessment;
(4) the most recent PDP;
(5) the most recent implementation plan for individualized
skills and socialization; and
(6) other documentation that supports the individual's
request for an enhanced staffing rate, which may include:
(A) the behavior support plan;
(B) a physician's order;
(C) an assessment completed by a service provider of
a professional therapy;
(D) the nursing assessment; and
(E) the CFC PAS/HAB assessment.
(e) HHSC approves a request made in accordance with
subsections (a) - (d) of this section if the documentation submitted
to HHSC demonstrates that to participate in off-site individualized
skills and socialization, the individual requires more service provider
support than the individual typically receives. The requirement for
additional support may be because of the individual's mobility, medical,
or behavioral needs.
(f) HHSC may review an approved enhanced staffing rate
at any time to determine if it is appropriate. If HHSC reviews an
enhanced staffing rate, a program provider or service coordinator
must submit documentation supporting the enhanced staffing rate to
HHSC in accordance with HHSC's request.
(g) HHSC notifies a program provider or service coordinator
that an enhanced staffing rate is approved or denied through the HHSC
data system.
(h) A service coordinator must notify the CDS employer
and FMSA of HHSC's approval or denial described in subsection (g)
of this section.
(i) A program provider may request an administrative
hearing in accordance with 1 TAC §357.484 (relating to Request
for a Hearing) if HHSC:
(1) denies a request made in accordance with subsection
(a) or (b) of this section; or
(2) denies an enhanced staffing rate based on a review
described in subsection (f) of this section.
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