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RULE §351.4Covered Services

    (R) Home health nursing services. Home health nursing services must be medically necessary, be prescribed by a physician, and be provided only by a licensed and certified home and community support services agency participating in the program. Home health nursing services are limited to 200 hours per client per calendar year. Up to 200 additional hours of service per client per calendar year may be approved with documented justification of need and cost effectiveness.

    (S) Hospice care. Hospice care includes palliative care for clients with a presumed life expectancy of six months or less during the last weeks and months before death. Services apply to care for the hospice terminal diagnosis condition or illnesses. Treatment for conditions unrelated to the terminal condition or illnesses is unaffected. Hospice care must be prescribed by a practitioner licensed to do so who also is enrolled as a program provider.

  (4) Care management.

    (A) Medical home. Each program client should receive care in the context of a medical home.

      (i) Comprehensive, coordinated health care of infants, children, and adolescents should encompass the following services:

        (I) provision of preventive care, including but not limited to, immunizations, growth and development assessments, appropriate screening health care supervision, client and parental counseling about health care supervision, and client and parental counseling about health and psychological issues;

        (II) assurance of ambulatory and inpatient care for acute illness, 24 hours a day, seven days a week (including after hours and weekends);

        (III) provision of care over an extended period of time to enhance continuity;

        (IV) identification of the need for sub-specialty consultation and referrals, provision of medical information about the client to the consultant, evaluation of the consultant's recommendations, implementation of recommendations that are indicated and appropriate, and interpretation of the consultant's recommendations for the family;

        (V) interaction with school and community agencies to assure that the special health needs of the client are addressed;

        (VI) guidance and assistance needed to make the transition to all aspects of adult life, including adult health care, work, and independence; and

        (VII) maintenance of a central record and database containing all pertinent medical information about the client including information about hospitalizations.

      (ii) The CSHCN Services Program may require periodic reports from the medical home.

    (B) Case management. Case management services may be made available to program clients through public health regional offices or other resources to assist clients and their families in obtaining adequate and appropriate services to meet the client's health and related services needs. The program will make available case management as needed or desired to all clients who are eligible for health care benefits (includes clients who are on the waiting list for health care benefits). The program also may make available case management services to clients who are not eligible for the program's health care benefits.

  (5) Family support services. Family support services include disability-related support, resources, or other assistance and may be provided to the family of a client with special health care needs.

    (A) Eligibility. A client is eligible to receive family support services if:

      (i) the client is not receiving services from a Medicaid waiver program, and the family support needs cannot be met by services from other family support programs, such as the Department of Aging and Disability Services or the In-Home and Family Support Program; and

      (ii) the client's family collaborates with the assigned case manager to identify and pursue other sources of support and to develop a family assessment and service plan.

    (B) Processing and evaluation of requests.

      (i) Families of clients indicate their need for family support services by completing and signing an approved request form.

      (ii) Requests for family support services are processed in chronological order by the date of the request.

      (iii) All requests for family support services must be prior authorized (approved by the program prior to delivery).

      (iv) While there is a waiting list for health care benefits, limitations in reimbursement or prior authorization may be instituted as provided in §38.16 of this title.

      (v) Some services or items may require a written statement from a physician, physical therapist, occupational therapist, or other healthcare professional to establish the disability-related nature of the request.

      (vi) Some services or items may require written bids.

      (vii) Persons requesting assistance are responsible for collaborating with their case managers to obtain information as necessary so that an accurate determination can be made in a timely manner.

      (viii) Families shall be notified in writing of the outcome of their requests for family support services.

      (ix) Families have the right to appeal a denial or partial approval as described in §38.13 of this title (relating to Right of Appeal).

    (C) Service plan and cost allowances.

      (i) The case manager and the client or family must develop a family assessment and service plan and complete a Family Support Services request packet to request a prior authorization for family support services.

      (ii) The program may establish annual cost allowances based upon the client's or family's level of assessed need for family support services not to exceed:

        (I) lifetime benefit of up to $3,600 per eligible client for minor home modifications; and

        (II) annual benefit of up to $3,600 per calendar year per eligible client for allowable family support services.

          (-a-) The annual benefit may increase to no more than $7,200 per eligible client for the purchase of vehicle lifts and modifications.

          (-b-) The lifetime benefit for minor home modifications and the annual benefit may be used in the same calendar year.

      (iii) Service plan cost allowances may be prorated for plans that cover less than one calendar year.

      (iv) Reimbursement:

        (I) may be made to the family or to the vendor enrolled as a program provider; and

        (II) may be reduced by the amount of a cost-sharing requirement, if applicable.

      (v) Reimbursement rates for respite providers are established by the client or family and the selected provider in collaboration with the case manager.

      (vi) The annual family assessment and service plan may be amended at any time, but must be reevaluated by the client or family and case manager at least annually.

    (D) Allowable services.

      (i) Family support services for program clients and their families include those allowable services and items that:

        (I) are above and beyond the scope of usual needs (i.e., basic clothing, food, shelter, medical care, and education);

        (II) are necessitated by the client's medical condition or disability; and

        (III) directly support the client's living in his or her natural home and participating in family life and community activities.

      (ii) Family support services may not be used to supplant services available through other public or private programs, but may be used to supplement services provided by other programs.

      (iii) Allowable services include:

        (I) respite care;

        (II) specialized child care costs for a client that are expenses directly related to the client's disability and special needs that are beyond the scope of community-based child care centers, including specialized training for the child care provider;

        (III) counseling, training programs, or conferences to obtain specific skills or knowledge related to the client's care that assists family members or caregiver(s) in maintaining the client in their home and to increase their knowledge and ability to care for the client;

        (IV) minor home modifications such as installation of a ramp, widening of doorways, bathroom modifications, and other home modifications to increase accessibility and safety;

        (V) vehicle lifts and modifications, such as wheelchair lifts or ramps, wheelchair tie-downs, occupant restraints, accessories, modifications such as raising roofs or doors if necessary for lift installation or usage, hand controls, and repairs of covered modifications not related to inappropriate handling or misuse of equipment and not covered by other resources;

        (VI) specialized equipment, including porch or stair lifts, air purification systems or air conditioners, positioning equipment, bath aids, supplies prescribed by licensed practitioners that are not covered through other systems, and other non-medical disability-related equipment that assists with family activities, promotes the client's self-reliance, or otherwise supports the family; and

        (VII) other disability-related services that support permanency planning, independence, or participation in family life and integrated or inclusive community activities.

    (E) Unallowable services. Family support funds may not be used to provide those services that do not relate to the client's disability and do not directly support the client's living in his or her natural home and participating in family life and integrated or inclusive community activities. Examples of unallowable services include, but are not limited to:

      (i) items for which a less expensive alternative of comparable quality is available;

      (ii) purchase or lease of vehicles or vehicle maintenance and repair;

      (iii) home mortgage or rent expenses or basic home maintenance and repair;

      (iv) income taxes;

      (v) medical services;

      (vi) services in segregated settings other than respite facilities or camps;

      (vii) insurance premiums;

      (viii) death benefits, burial policies, and funeral expenses;

      (ix) costs for allowable services incurred before the requested family support service is prior authorized;

      (x) non-medical foods, routine shelter, routine utilities, routine home repairs, routine home appliances, routine furnishings, fences, and yard work;

      (xi) medical benefit items or services paid for or reimbursed by private insurance, Medicaid, Medicare, CHIP, the CSHCN Services Program or other health insurance programs for which the client is eligible;

      (xii) services, equipment, or supplies that have been denied by Medicaid, CHIP, or the program because a claim was received after the filing deadline, because insufficient information was submitted, or because an item was considered inappropriate or experimental;

      (xiii) over-the-counter or prescription medications;

      (xiv) architectural modifications to a public facility;

      (xv) school tuition or fees, or equipment, items, or services that should be provided through the public school system;

      (xvi) items that could endanger the health and safety of the client;

      (xvii) routine child care;

      (xviii) computers and software unless for use as an assistive technology device or necessary to perform a critical or essential function, such as environmental control or written or oral communication, which the client is unable to perform without the computer;

      (xix) services provided by an individual under the age of 18 years or by the client's parent(s), guardian, or other individual(s) residing with the client; and

      (xx) services exclusively to support the care of siblings or other individual(s) residing with the client, but which are not necessary to meet the medical needs of the client.

    (F) Reduction or termination of services. Reasons for terminating or reducing family support services may include, but are not limited to:

      (i) the client no longer meets the eligibility criteria for the program;

      (ii) services available through the program are discontinued due to budget restrictions;

      (iii) While there is a waiting list for health care benefits, limitations in reimbursement or prior authorization may be instituted as provided in §38.16 of this title;

      (iv) the client's family indicates that the need for family support services no longer exists;

      (v) the client moves out of Texas;

      (vi) the client is placed in a nursing facility or other institutional setting for an indefinite period of time;

      (vii) the client dies;

      (viii) the client's designated case manager is unable to locate the client and family; or


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