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TITLE 40SOCIAL SERVICES AND ASSISTANCE
PART 1DEPARTMENT OF AGING AND DISABILITY SERVICES
CHAPTER 9INTELLECTUAL DISABILITY SERVICES--MEDICAID STATE OPERATING AGENCY RESPONSIBILITIES
SUBCHAPTER DHOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC)
RULE §9.155Eligibility Criteria and Suspension of HCS Program Services and of CFC Services

(a) An applicant or individual is eligible for HCS Program services if he or she:

  (1) meets the financial eligibility criteria as described in Appendix B of the HCS Program waiver application approved by CMS and found at www.dads.state.tx.us;

  (2) meets one of the following criteria:

    (A) based on a determination of an intellectual disability performed in accordance with THSC, Chapter 593, Subchapter A and as determined by DADS in accordance with §9.161 of this subchapter (relating to LOC Determination), qualifies for an ICF/IID LOC I as defined in §9.238 of this chapter (relating to ICF/MR Level of Care I Criteria);

    (B) as determined by DADS in accordance with §9.161 of this subchapter, qualifies for an ICF/IID LOC I as defined in §9.238 of this chapter or ICF/IID LOC VIII as defined in §9.239 of this chapter (relating to ICF/MR Level of Care VIII Criteria), and has been determined by DADS:

      (i) to have an intellectual disability or a related condition;

      (ii) to need specialized services; and

      (iii) to be inappropriately placed in a Medicaid certified nursing facility based on an annual resident review conducted in accordance with the requirements of Chapter 17 of this title (relating to Preadmission Screening and Resident Review (PASRR)); or

    (C) meets the following criteria:

      (i) based on a determination of an intellectual disability performed in accordance with THSC, Chapter 593, Subchapter A and as determined by DADS in accordance with §9.161 of this subchapter, qualifies for one of the following levels of care:

        (I) an ICF/IID LOC I as defined in §9.238 of this chapter; or

        (II) an ICF/IID LOC VIII as defined in §9.239 of this chapter;

      (ii) meets one of the following:

        (I) resides in a nursing facility immediately prior to enrolling in the HCS Program; or

        (II) is at imminent risk of entering a nursing facility as determined by DADS; and

      (iii) is offered HCS Program services designated for a member of the reserved capacity group "Individuals with a level of care I or VIII residing in a nursing facility" included in Appendix B of the HCS Program waiver application approved by CMS and found at www.dads.state.tx.us;

  (3) has an IPC cost that does not exceed:

    (A) $167,468 for an applicant or individual with an LON 1, LON 5, or LON 8;

    (B) $168,615 for an applicant or individual with an LON 6; or

    (C) $305,877 for an applicant or individual with an LON 9;

  (4) is not enrolled in another waiver program and is not receiving a service that may not be received if the individual is enrolled in the HCS Program as identified in the Mutually Exclusive Services table in Appendix II of the HCS Handbook available at www.dads.state.tx.us;

  (5) does not reside in:

    (A) an ICF/IID;

    (B) a nursing facility;

    (C) an assisted living facility licensed or subject to being licensed in accordance with THSC, Chapter 247;

    (D) a residential child-care operation licensed or subject to being licensed by DFPS unless it is a foster family home or a foster group home;

    (E) a facility licensed or subject to being licensed by the Department of State Health Services (DSHS);

    (F) a facility operated by DARS;

    (G) a residential facility operated by the Texas Juvenile Justice Department, a jail, or a prison; or

    (H) a setting in which two or more dwellings, including units in a duplex or apartment complex, single family homes, or facilities listed in subparagraphs (A) - (G) of this paragraph, excluding supportive housing under Section 811 of the National Affordable Housing Act of 1990, meet all of the following criteria:

      (i) the dwellings create a residential area distinguishable from other areas primarily occupied by persons who do not require routine support services because of a disability;

      (ii) most of the residents of the dwellings are persons with an intellectual disability; and

      (iii) the residents of the dwellings are provided routine support services through personnel, equipment, or service facilities shared with the residents of the other dwellings; and

  (6) requires the provision of:

    (A) at least one HCS Program service per month or a monthly monitoring visit by a service coordinator as described in §9.190(e)(41) of this subchapter (relating to LIDDA Requirements for Providing Service Coordination in the HCS Program); and

    (B) at least one HCS Program service per IPC year.

(b) For applicants or individuals with spouses who live in the community, the income and resource eligibility requirements are determined according to the spousal impoverishment provisions in §1924 of the Social Security Act and as specified in the Medicaid State Plan.

(c) Except as provided in subsection (d), an applicant or individual is eligible for a CFC service under this subchapter if the applicant or individual:

  (1) meets the criteria described in subsection (a) of this section;

  (2) requires the provision of the CFC service; and

  (3) is not receiving host home/companion care, supervised living, or residential support.

(d) To be eligible for a CFC service under this subchapter, an applicant or individual receiving MAO Medicaid must, in addition to meeting the eligibility criteria described in subsection (c) of this section, receive an HCS Program service at least monthly, as required by 42 CFR §441.510(d), which may not be met by a monthly monitoring visit by a service coordinator as described in §9.190(e)(41) of this subchapter.

(e) If an individual is temporarily admitted to one of the following settings, the individual's HCS Program services and CFC services are suspended during that admission:

  (1) a hospital;

  (2) an ICF/IID;

  (3) a nursing facility;

  (4) a residential child-care operation licensed or subject to being licensed by DFPS;

  (5) a facility licensed or subject to being licensed by the DSHS;

  (6) a facility operated by DARS;

  (7) a residential facility operated by the Texas Juvenile Justice Department, a jail, or a prison; or

  (8) an assisted living facility licensed or subject to being licensed in accordance with THSC, Chapter 247.


Source Note: The provisions of this §9.155 adopted to be effective March 1, 2000, 25 TexReg 1649; amended to be effective September 1, 2001, 26 TexReg 5823; amended to be effective September 1, 2003, 28 TexReg 6885; amended to be effective August 31, 2004, 29 TexReg 8333; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; amended to be effective June 1, 2006, 31 TexReg 4442; amended to be effective June 1, 2008,33 TexReg 4334; amended to be effective June 1, 2010,35 TexReg 4441; amended to be effective September 1, 2014, 39 TexReg 6516; amended to be effective November 15, 2015, 40 TexReg 7827; amended to be effective March 20, 2016, 41 TexReg 1867

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