| (a) A LIDDA must request an LOC from HHSC for an applicant
in accordance with this subsection.
(1) The LIDDA must complete an ID/RC Assessment for
an applicant that:
(A) includes the LOC recommended by a person qualified
to perform an initial evaluation of LOC in accordance with Appendix
B of the HCS Program waiver application approved by CMS; and
(B) is signed and dated in accordance with the instructions
for completing the ID/RC Assessment.
(2) The LIDDA must enter information from the completed
ID/RC Assessment in the HHSC data system and electronically submit
the information to HHSC.
(3) The LIDDA must ensure that the information entered
in the HHSC data system and electronically submitted to HHSC is identical
to the information on the completed ID/RC Assessment.
(4) The LIDDA must send a copy of the completed ID/RC
Assessment and supporting documentation to HHSC, as requested by HHSC.
(b) A program provider must request an LOC for an individual
from HHSC in accordance with this subsection.
(1) No more than 60 calendar days before the expiration
date of an individual's ID/RC Assessment, a program provider must:
(A) complete an ID/RC Assessment that:
(i) includes the LOC recommended by a person qualified
to perform a reevaluation of LOC in accordance with Appendix B of
the HCS Program waiver application approved by CMS; and
(ii) is signed and dated by the program provider in
accordance with the instructions for completing the ID/RC Assessment;
and
(B) enter information from the completed ID/RC Assessment
in the HHSC data system and electronically submit the information.
(2) A program provider must:
(A) ensure that the information entered and electronically
submitted in the HHSC data system is identical to the information
on the completed ID/RC Assessment;
(B) within three calendar days after entering and electronically
submitting the information in the HHSC data system, provide the service
coordinator with a copy of the completed ID/RC Assessment; and
(C) send a copy of the completed ID/RC Assessment and
supporting documentation to HHSC, as requested by HHSC.
(3) If the program provider enters information from
a completed ID/RC Assessment in the HHSC data system and electronically
submits the information on a date that is more than 180 calendar days
after the expiration date of the previous ID/RC Assessment, the program
provider must:
(A) send to HHSC a copy of the completed ID/RC Assessment
by a method, as instructed by HHSC, that:
(i) includes the recommended LOC; and
(ii) is signed and dated by the program provider in
accordance with the instructions for completing the ID/RC Assessment;
(B) within three calendar days after sending the completed
ID/RC Assessment to HHSC, provide the service coordinator with a copy
of the completed ID/RC Assessment; and
(C) submit documentation supporting the ID/RC Assessment
to HHSC, as requested by HHSC.
(c) For an LOC requested in accordance with subsection
(b) of this section, within seven calendar days after a program provider
enters information from a completed ID/RC Assessment in the HHSC data
system and electronically submits the information, the service coordinator
or a LIDDA representative other than the service coordinator must:
(1) review the information entered in the HHSC data
system and electronically submitted, to determine if the information
in the HHSC data system is identical to the information on the completed
ID/RC Assessment the service coordinator received from the program
provider;
(2) enter in the HHSC data system:
(A) the service coordinator's name and date of review;
and
(B) one of the following:
(i) that the service coordinator agrees with the ID/RC
Assessment, if the information in the HHSC data system is identical
to the completed ID/RC Assessment; or
(ii) that the service coordinator disagrees with the
ID/RC Assessment, if the information in the HHSC data system is not
identical to the completed ID/RC Assessment; and
(3) if the service coordinator or a LIDDA representative
other than the service coordinator enters in the HHSC data system
that the service coordinator disagrees with the ID/RC Assessment,
notify HHSC and the program provider of the service coordinator's
disagreement in accordance with HHSC's instructions.
(d) For an LOC requested in accordance with subsection
(b) of this section, HHSC considers a service coordinator's agreement
or disagreement with an ID/RC Assessment in making an LOC determination.
(e) Information on an ID/RC Assessment must be supported
by current data obtained from standardized evaluations and formal
assessments that measure physical, emotional, social, and cognitive
factors. A signed and dated ID/RC Assessment and documentation supporting
the recommended LOC must be maintained in an individual's record.
(f) When HHSC receives a request for an LOC in accordance
with subsection (a) or (b) of this section, HHSC determines if an
applicant or individual qualifies for an LOC required by §263.101(a)(2)
of this subchapter (relating to Eligibility Criteria for HCS Program
Services and CFC Services).
(g) HHSC approves an LOC or sends a 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 §263.801 of this
chapter (relating to Fair Hearing);
(2) to the LIDDA that the LOC has been denied; and
(3) to the program provider using the HHSC data system
that the LOC has been denied, if the applicant has selected a program
provider or an individual is receiving services from a program provider.
(h) An LOC determination is valid for a period of time
as described in this subsection.
(1) Except as provided in paragraph (2) of this subsection,
an LOC determination is valid for a 365-calendar day period starting
on the begin date of the ID/RC Assessment.
(2) If the begin date of the ID/RC Assessment is March
1 or later in a year before a leap year or January 1-February 28 of
a leap year, the LOC determination is valid for a 366-calendar day
period starting on the begin date of the ID/RC Assessment.
(i) An ID/RC Assessment submitted in accordance with
subsection (b) of this section is effective on the date after the
individual's previous ID/RC Assessment expires.
(j) 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,
HHSC notifies the LIDDA of the change using the HHSC HCS Level of
Care Redetermination Cover Sheet form.
(1) The LIDDA must, within 30 business days after receiving
the notification:
(A) conduct a DID in accordance with §304.401
of this title (relating to Conducting a Determination of Intellectual
Disability);
(B) complete the LIDDA section of the HHSC HCS Level
of Care Redetermination Cover Sheet form, and return the form to HHSC;
and
(C) submit a copy of the results of the new DID and
any other pertinent information regarding the reassessment of the
individual to HHSC.
(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 HHSC of the reasons for the delay.
(3) HHSC reviews the information submitted by the LIDDA
regarding the redetermination and notifies the LIDDA and the HCS program
provider of the review decision using the HHSC HCS Level of Care Redetermination
Cover Sheet form.
(k) For an individual who is receiving all services
through the CDS option and, therefore, does not have a program provider,
the service coordinator:
(1) must perform the functions of the program provider
described in subsection (b) of this section; and
(2) is not required to comply with subsection (c) of
this section.
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