| (a) A program provider may request a level one enhanced
staffing rate for off-site individualized skills and socialization
described in §263.2025(b) of this subchapter (relating to Program
Provider Reimbursement for Individualized Skills and Socialization)
for an individual with a LON 1 or LON 5 by submitting the following
documentation to HHSC:
(1) a completed HHSC Enhanced Staffing Rate Request
Form;
(2) the most recent ICAP scoring booklet;
(3) the most recent ID/RC Assessment;
(4) the most recent PDP;
(5) the most recent implementation plan for individualized
skills and socialization; and
(6) other documentation that supports the individual's
request for an enhanced staffing rate, which may include:
(A) the behavior support plan;
(B) a physician's order;
(C) an assessment completed by a service provider of
a professional therapy;
(D) the nursing assessment; and
(E) the CFC PAS/HAB assessment.
(b) A program provider may request a level two enhanced
staffing rate for off-site individualized skills and socialization
described in §263.2025(b) of this subchapter for an individual
with a LON 1, LON 5, LON 8, or LON 6 by submitting the documentation
described in subsection (a) of this section.
(c) HHSC approves a request made in accordance with
subsection (a) or (b) of this section if the documentation submitted
to HHSC demonstrates that to participate in off-site individualized
skills and socialization, the individual requires more service provider
support than the individual would receive with the individual's assigned
LON. The requirement for additional support may be because of the
individual's mobility, medical, or behavioral needs.
(d) HHSC may review an approved enhanced staffing rate
at any time to determine if it is appropriate. If HHSC reviews an
enhanced staffing rate, a program provider must submit documentation
supporting the enhanced staffing rate to HHSC in accordance with HHSC's
request.
(e) HHSC notifies a program provider that an enhanced
staffing rate is approved or denied through the HHSC data system.
(f) A program provider may request an administrative
hearing in accordance with 1 TAC §357.484 (relating to Request
for a Hearing) if HHSC:
(1) denies a request made in accordance with subsection
(a) or (b) of this section; or
(2) denies an enhanced staffing rate based on a review
described in subsection (d) of this section.
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