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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 NTEXAS HOME LIVING (TXHML) PROGRAM AND COMMUNITY FIRST CHOICE (CFC)
RULE §9.556Eligibility Criteria for TxHmL Program Services and CFC Services

(a) An applicant or individual is eligible for TxHmL Program services if:

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

  (2) the applicant or individual 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 §9.560 of this subchapter (relating to Level of Care (LOC) Determination), qualifies for an ICF/IID LOC I as defined in §9.238 of this chapter (relating to Level of Care I Criteria); or

    (B) 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 §9.560 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 (relating to ICF/MR Level of Care VIII Criteria);

      (ii) meets one of the following:

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

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

      (iii) is offered TxHmL 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 TxHmL Program waiver application approved by CMS and found at www.dads.state.tx.us;

  (3) the applicant or individual has been assigned an LON 1, 5, 8, or 6 in accordance with §9.562 of this subchapter (relating to Level of Need (LON) Assignment);

  (4) the applicant or individual has an IPC cost that does not exceed $17,000;

  (5) the applicant or individual 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 TxHmL Program, as identified in the Mutually Exclusive Services table in Appendix I of the HCS Handbook available at www.dads.state.tx.us;

  (6) the applicant or individual has chosen, or the applicant's or individual's LAR has chosen, participation in the TxHmL Program over participation in the ICF/IID Program;

  (7) the applicant's or individual's service planning team concurs that the TxHmL Program services and, if applicable, non-TxHmL Program services for which the applicant or individual may be eligible are sufficient to ensure the applicant's or individual's health and welfare in the community;

  (8) the applicant or individual lives in the applicant's or individual's own home or family home; and

  (9) the applicant or individual requires the provision of:

    (A) at least one TxHmL Program service per month or a monthly monitoring visit by a service coordinator as described in §9.583(p) of this subchapter (relating to TxHmL Program Principles for LIDDAs); and

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

(b) Except as provided in subsection (c) of this section, 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; and

  (2) requires the provision of the CFC service.

(c) 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 (b) of this section, receive a TxHmL 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 §9.583(p) of this subchapter.


Source Note: The provisions of this §9.556 adopted to be effective November 15, 2015, 40 TexReg 7827; amended to be effective March 20, 2016, 41 TexReg 1867

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