| (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
Cont'd... |
