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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 §9.161LOC Determination

(a) A LIDDA must request an LOC from DADS for an applicant at the time the applicant is enrolled into the HCS Program. The LOC is requested by electronically transmitting a completed ID/RC Assessment to DADS, indicating the recommended LOC, signed and dated by the service coordinator. The electronically transmitted ID/RC Assessment must contain information identical to the information on the signed and dated ID/RC Assessment.

(b) A program provider must request an LOC for an individual from DADS in accordance with this subsection.

  (1) Before the expiration of an ID/RC Assessment, the program provider must electronically transmit to DADS a completed ID/RC Assessment, indicating the recommended LOC, that is signed and dated by the program provider.

  (2) The program provider must ensure the electronically transmitted ID/RC Assessment contains information that is identical to the information on the signed and dated ID/RC Assessment.

  (3) The program provider must, within three calendar days after transmission, provide the service coordinator with a paper copy of the signed and dated ID/RC Assessment.

(c) For an LOC requested in accordance with subsection (b) of this section, within seven calendar days after the ID/RC Assessment is electronically transmitted by the program provider, the service coordinator must review the ID/RC Assessment in the DADS data system and:

  (1) enter the service coordinator's name and date in the DADS data system;

  (2) enter in the DADS data system whether the service coordinator agrees or disagrees with the ID/RC Assessment; and

  (3) if the service coordinator disagrees with the ID/RC Assessment, notify the individual, LAR, DADS, and the program provider of the service coordinator's disagreement in accordance with DADS instructions.

(d) The service coordinator's agreement or disagreement will be considered in DADS review of an ID/RC Assessment transmitted in accordance with subsection (b) of this section.

(e) For an LOC requested under subsection (a) or (b) of this section, DADS makes an LOC determination in accordance with §9.238 of this chapter (relating to ICF/MR Level of Care I Criteria) and §9.239 of this chapter (relating to ICF/MR Level of Care VIII Criteria) based on DADS review of information reported on the applicant's or individual's ID/RC Assessment.

(f) Information on the ID/RC Assessment must be supported by current data obtained from standardized evaluations and formal assessments that measure physical, emotional, social, and cognitive factors. The signed and dated ID/RC Assessment and documentation supporting the recommended LOC must be maintained in the individual's record.

(g) DADS approves the LOC or sends written notification:

  (1) to the applicant, individual, or LAR that the applicant or individual is not eligible for HCS Program services or CFC services and provides the applicant, individual, or LAR with an opportunity to request a fair hearing in accordance with §9.169 of this subchapter (relating to Fair Hearing); and

  (2) to the LIDDA and program provider that the LOC has been denied.

(h) An LOC determination is valid for 364 calendar days after the LOC effective date determined by DADS.

(i) If the LON of an individual receiving HCS Program services changes from a LON 5, LON 8, LON 6, or LON 9 to a LON 1, DADS notifies the LIDDA of the change using DADS Form 1597, HCS Level of Care Redetermination Cover Sheet.

  (1) The LIDDA must, within 30 business days after receiving the notification:

    (A) assess the individual in-person and complete a new Determination of Intellectual Disability (DID) in accordance with Chapter 5, Subchapter D of this title (relating to Diagnostic Eligibility for Services and Supports--Intellectual Disability Priority Population and Related Conditions);

    (B) complete the LIDDA section of DADS Form 1597, HCS Level of Care Redetermination Cover Sheet, and return the form to DADS; and

    (C) submit a copy of the results of the new DID and any other pertinent information regarding the reassessment of the individual to DADS.

  (2) If the LIDDA is unable to complete the requirements described in paragraph (1) of this subsection within the 30 business day timeframe, the LIDDA must notify DADS of the reasons for the delay.

  (3) DADS reviews the information submitted by the LIDDA regarding the redetermination and notifies the LIDDA and the HCS Program provider of the review decision using DADS Form 1597, HCS Level of Care Redetermination Cover Sheet.


Source Note: The provisions of this §9.161 adopted 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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