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TITLE 40SOCIAL SERVICES AND ASSISTANCE
PART 1DEPARTMENT OF AGING AND DISABILITY SERVICES
CHAPTER 45COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES AND COMMUNITY FIRST CHOICE (CFC) SERVICES
SUBCHAPTER BELIGIBILITY, ENROLLMENT, AND REVIEW
DIVISION 2ENROLLMENT PROCESS
RULE §45.214Development of Enrollment IPC

(a) A CMA must, within 30 calendar days after notification by the DSA of HHSC's decision that an individual meets the LOC VIII criteria, as required by §45.212(k) of this division (relating to Process for Enrollment of an Individual), ensure that an individual's case manager:

  (1) convenes a service planning team meeting in which the service planning team:

    (A) reviews the CLASS/DBMD Nursing Assessment form completed by the RN;

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

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

    (D) develops a PAS/HAB plan based on information obtained from assessments conducted and observations made by the DSA as required by §45.212(h) of this division;

    (E) develops a proposed enrollment IPC that:

      (i) identifies the type of 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 the individual;

      (iii) for each CLASS Program service:

        (I) is within the service limit described in §45.218 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;

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

      (v) states 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; and

      (vii) if it includes registered nursing, licensed vocational nursing, specialized registered nursing, specialized licensed vocational nursing, habilitation, or CFC PAS/HAB, identifies whether the service is critical to the individual's health and safety, as required by §45.231(a)(2) of this subchapter (relating to Service Backup Plans);

    (F) develops an IPP for each CLASS Program service and CFC service listed on the proposed enrollment IPC, other than CFC support management; and

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

  (2) if the individual may need cognitive rehabilitation therapy, begin assisting the individual in obtaining an assessment as required by §45.705(h) of this chapter (relating to CMA Service Delivery).

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

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

  (2) addresses the individual's related condition;

  (3) is not available to the 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 the individual's needs; and

  (5) is cost effective.

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

  (1) ensure that during the service planning team meeting required by subsection (a)(1) of this section 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; and

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

    (A) submit the following to HHSC for its review:

      (i) the proposed enrollment IPC;

      (ii) the IPPs;

      (iii) the PAS/HAB plan;

      (iv) the completed HHSC CLASS/DBMD Nursing Assessment form provided by the DSA in accordance with §45.212(i)(3) of this division; and

      (v) if transportation as a habilitation activity or as an adaptive aid is included on the IPC, the transportation plan;

    (B) send to the DSA a copy of:

      (i) the proposed enrollment IPC;

      (ii) the IPPs;

      (iii) any service backup plan; and

      (iv) if required by subsection (a)(1)(G) of this section, the transportation plan to the DSA; and

    (C) if the individual will receive a service through the CDS option, send to the FMSA a copy of the proposed enrollment IPC, the IPP for each service the individual will receive through the CDS option, the PAS/HAB plan and, if required by subsection (a)(1)(G) of this section, the transportation plan.

(d) If the individual or LAR requests a CLASS Program service or CFC service that the 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 §45.218 of this division, the CMA must comply with this subsection.

  (1) The CMA must, in accordance with the CLASS Provider Manual, send the individual or LAR written notice of the denial of the requested CLASS Program service or CFC service, copying the DSA and FMSA, if the individual or LAR requests a CLASS Program service or CFC service that the CMA or DSA has determined:

    (A) does not meet the criteria described in subsection (b) of this section;

    (B) does not meet the requirements described in Subchapter F of this chapter; or

    (C) exceeds a service limit described in §45.218 of this division.

  (2) If the CMA is required to send written notice of denial of a CLASS Program service or CFC service as described in paragraph (1) of this subsection, the CMA must also:

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

      (i) the proposed enrollment IPC that includes the type and amount of CLASS Program services or CFC services in dispute and not in dispute and is signed and dated by:

        (I) the individual or LAR;

        (II) the case manager; and

        (III) the DSA;

      (ii) the IPPs;

      (iii) the PAS/HAB plan; and

      (iv) if transportation as a habilitation activity or as an adaptive aid is included on the IPC, the transportation plan; and

    (B) if the individual will receive a service through the CDS option, send to the FMSA a copy of the proposed enrollment IPC, the IPP for each service the individual will receive through the CDS option, the PAS/HAB plan, and if required by subsection (a)(1)(G) of this section, the transportation plan.

(e) HHSC reviews a proposed enrollment IPC in accordance with §45.216 of this division (relating to HHSC's Review of an Enrollment IPC).

(f) The process by which an individual's request for enrollment or a CLASS Program service or CFC service is denied, based on HHSC's review of a proposed enrollment IPC, is described in §45.216(d) - (f) of this division.

(g) The effective date of an enrollment IPC is one of the following, whichever is later:

  (1) the effective date as determined by the service planning team; or

  (2) the date HHSC notifies the CMA that the individual's request for enrollment is approved and the IPC is authorized in accordance with §45.216(c) or (e)(2)(C) of this division.

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

(i) An individual's enrollment IPC must be reviewed and updated in accordance with §45.223 of this subchapter (relating to Renewal and Revision of an IPC).


Source Note: The provisions of this §45.214 adopted to be effective March 21, 2011, 36 TexReg 1840; amended to be effective December 1, 2011, 36 TexReg 8049; amended to be effective July 1, 2015, 40 TexReg 2768; amended to be effective November 15, 2015, 40 TexReg 7883; amended to be effective March 20, 2016, 41 TexReg 1952; amended to be effective October 1, 2019, 44 TexReg 5118

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