Current through Reg. 49, No. 38; September 20, 2024
(a) After HHSC
notifies a CMA, as described in §259.55(c) of this division (relating to
Written Offer of CLASS Program Services), that an individual selected the CMA,
the CMA must assign a case manager to perform the following functions as soon
as possible, but no later than 14 calendar days after HHSC's notification:
(1) verify that the individual resides in the
catchment area for which the individual's selected CMA and DSA have a
contract;
(2) conduct an initial
in-person visit in the individual's residence with the individual and LAR or
actively involved person at a time convenient to the individual and LAR to:
(A) provide an oral and written explanation
of the following to the individual and LAR or actively involved person:
(i) CLASS Program services, including TAS if
the individual is receiving institutional services;
(ii) CFC services;
(iii) the mandatory participation
requirements of an individual described in §
259.103 of this chapter (relating
to Mandatory Participation Requirements of an Individual);
(iv) the CDS option described in §259.71
of this division (relating to CDS Option);
(v) the right to request a fair hearing in
accordance with §
259.101 of this chapter (relating
to Individual's Right to a Fair Hearing);
(vi) that the individual, LAR, or actively
involved person may report an allegation of abuse, neglect, or exploitation to
DFPS by calling the toll-free telephone number at 1-800-252-5400;
(vii) the process by which the individual,
LAR, or actively involved person may file a complaint regarding case management
as required by 40 TAC §
49.309(relating to Complaint
Process);
(viii) that the HHSC
Office of the Ombudsman toll-free telephone number at 1-877-787-8999 may be
used to file a complaint regarding the CMA;
(ix) voter registration, if the individual is
18 years of age or older;
(x) that,
while the individual is staying at a location outside the catchment area in
which the individual resides but within the state of Texas for a period of no
more than 60 consecutive days, the individual and LAR or actively involved
person may request that the DSA provide:
(I)
transportation as a habilitation activity, as described in §
259.5(56)(B)(i)(IX)
of this subchapter (relating to Definitions);
(II) out-of-home respite in a camp described
in §
259.361(b)(2)(D)
of this chapter (relating to Respite and Dental Treatment);
(III) adaptive aids;
(IV) nursing; and
(V) CFC PAS/HAB;
(xi) the use of electronic visit
verification, as required by 1 TAC Chapter 354, Subchapter O; and
(xii) how to contact the individual's case
manager; and
(B) use the
HHSC Understanding Program Eligibility - CLASS/DBMD form to provide an oral and
written explanation to the individual or LAR, and obtain the individual's or
LAR's signature and date on the form, to acknowledge understanding of:
(i) the eligibility requirements for:
(I) CLASS Program services, as described in
§
259.51(a) of this
subchapter (relating to Eligibility Criteria for CLASS Program Services and CFC
Services);
(II) CFC services for
individuals who do not receive MAO Medicaid, as described in §
259.51(b) of this
subchapter; and
(III) CFC services
for individuals who receive MAO Medicaid, as described in §
259.51(c) of this
subchapter;
(ii) the
reasons CLASS Program services and CFC services may be suspended, as described
in §
259.157 of this chapter (relating
to Suspension of CLASS Program Services or CFC Services); and
(iii) that CLASS Program services and CFC
services may be terminated as described in §§
259.161,
259.163,
259.165, and
259.167 of this chapter (relating
to Termination of CLASS Program Services and CFC Services With Advance Notice
for Reasons Other Than Non-compliance with Mandatory Participation
Requirements; Termination of CLASS Program Services and CFC Services With
Advance Notice Because of Non-compliance With Mandatory Participation
Requirements; Termination of CLASS Program Services and CFC Services Without
Advance Notice for Reasons Other Than Behavior Causing Immediate Jeopardy; and
Termination of CLASS Program Services and CFC Services Without Advance Notice
Because of Behavior Causing Immediate Jeopardy); and
(C) educate the individual, LAR, and actively
involved person about protecting the individual from abuse, neglect, and
exploitation; and
(3)
give the individual or LAR the HHSC Waiver Program Verification of Freedom of
Choice form to document the individual's or LAR's choice regarding the CLASS
Program or the ICF/IID Program.
(b) A CMA must:
(1) as soon as possible, but no later than
two business days after the case manager's initial in-person visit required by
subsection (a)(2) of this section:
(A) collect
the information necessary for the CMA and DSA to process the individual's
request for enrollment into the CLASS Program in accordance with the
Community Living Assistance and Support Services Provider
Manual; and
(B) provide
the individual's selected DSA with the information collected in accordance with
subparagraph (A) of this paragraph;
(2) assist the individual or LAR in
completing and submitting an application for Medicaid financial eligibility, as
required by §
259.103(1) of
this chapter; and
(3) ensure that
the case manager documents in the individual's record the progress toward
completing a Medicaid application and enrolling into the CLASS
Program.
(c) If an
individual or LAR does not submit a Medicaid application to HHSC within 30
calendar days after the case manager's initial in-person visit, as required by
§
259.103(1) of
this chapter, but is making good faith efforts to complete the application, the
CMA:
(1) may extend, in 30-calendar day
increments, the time frame in which the application must be submitted to HHSC,
except as provided in paragraph (2) of this subsection;
(2) must not grant an extension that results
in a time period of more than 365 calendar days from the date of the case
manager's initial in-person visit; and
(3) must ensure that the case manager
documents each extension in the individual's record.
(d) If an individual or LAR does not submit a
Medicaid application to HHSC within 30 calendar days after the case manager's
initial in-person visit, as required by §
259.103(1) of
this chapter, and is not making good faith efforts to complete the application,
a CMA must request, in writing, that HHSC withdraw the offer of enrollment made
to the individual in accordance with §259.55(d)(2) of this
division.
(e) If a DSA serving the
catchment area in which an individual resides is not willing to provide CLASS
Program services or CFC services to the individual because the DSA has
determined that it cannot ensure the individual's health and safety, the CMA
must provide to HHSC, in writing, the specific reasons the DSA has determined
that it cannot ensure the individual's health and safety.
(f) During the initial in-person visit
described in subsection (a)(1) of the section, the case manager must determine
whether an individual meets the following criteria:
(1) the individual is being discharged from a
nursing facility or an ICF/IID;
(2)
the individual has not previously received TAS;
(3) the individual's proposed enrollment IPC
will not include SFS; and
(4) the
individual anticipates needing TAS.
(g) If a case manager determines that an
individual meets the criteria described in subsection (f) of this section, the
case manager must:
(1) provide the individual
or LAR with a list of TAS providers in the catchment area in which the
individual will reside;
(2)
complete, with the individual or LAR, the HHSC Transition Assistance Services
(TAS) Assessment and Authorization form found on the HHSC website in accordance
with the form's instructions, which includes:
(A) identifying the items and services
described in §
272.5(e) of this
title (relating to Service Description) that the individual needs;
(B) estimating the monetary amount for the
items and services identified on the form, which must be within the service
limit described in §259.73(a)(4) of this division (relating to Service
Limits); and
(C) documenting the
individual's or LAR's choice of TAS provider;
(3) submit the completed form to HHSC for
authorization;
(4) if HHSC
authorizes the form, send the form to the TAS provider chosen by the individual
or LAR; and
(5) include TAS and the
monetary amount authorized by HHSC on the individual's proposed enrollment
IPC.
(h) A DSA must
ensure that the following functions are performed during an in-person visit in
the individual's residence at a time convenient to the individual and LAR as
soon as possible, but no later than 14 calendar days after the CMA provides
information to the DSA as required by subsection (b)(1)(B) of this section:
(1) a DSA staff person must:
(A) inform the individual and LAR or actively
involved person, orally and in writing:
(i)
that the individual, LAR, or actively involved person may report an allegation
of abuse, neglect, or exploitation to DFPS by calling the toll-free telephone
number at 1-800-252-5400;
(ii) the
process by which the individual, LAR, or actively involved person may file a
complaint regarding CLASS Program services or CFC services provided by the DSA
as required by 40 TAC §
49.309; and
(iii) that the HHSC Complaint and Incident
Intake toll-free telephone number at 1-800-458-9858 may be used to file a
complaint regarding the DSA; and
(B) educate the individual and LAR or
actively involved person about protecting the individual from abuse, neglect,
and exploitation;
(2) an
appropriate professional must complete an adaptive behavior screening
assessment in accordance with the assessment instructions; and
(3) an RN, in accordance with the Community
Living Assistance and Support Services Provider Manual, must complete:
(A) a nursing assessment, using the HHSC
CLASS/DBMD Nursing Assessment form;
(B) the HHSC Related Conditions Eligibility
Screening Instrument form; and
(C)
the ID/RC Assessment.
(i) A DSA must:
(1) ensure that the primary diagnosis of the
individual documented on the ID/RC Assessment is approved by a
physician;
(2) submit the following
documentation to HHSC for HHSC's determination of whether the individual meets
the LOC VIII criteria required by §
259.51(a)(2) of
this subchapter:
(A) the completed adaptive
behavior screening assessment;
(B)
the completed HHSC Related Conditions Eligibility Screening Instrument form;
and
(C) the completed ID/RC
Assessment; and
(3) send
the completed HHSC CLASS/DBMD Nursing Assessment form described in subsection
(h)(3)(A) of this section to the CMA.
(j) In accordance with §259.63(a)(1) of
this division (relating to Determination by HHSC of Whether an Individual Meets
LOC VIII Criteria), HHSC reviews the documentation described in subsection
(i)(2) of this section.
(k) If a
DSA receives written notice from HHSC in accordance with §259.63(c)(1) of
this division that an individual meets the LOC VIII criteria, the DSA must
notify the individual's CMA of HHSC's decision as soon as possible, but no
later than one business day after receiving the notice from HHSC.
(l) If HHSC determines that an individual
does not meet the LOC VIII criteria, HHSC sends written notice of the denial of
the individual's request for enrollment into the CLASS Program:
(1) to the individual or LAR in accordance
with §
259.153(b) of
this chapter (relating to Denial of a Request for Enrollment into the CLASS
Program); and
(2) to the
individual's DSA and CMA in accordance with §259.63(d) of this
division.
(m) If a CMA
receives notice from a DSA, as described in subsection (k) of this section,
that HHSC determined that an individual meets the LOC VIII criteria, the case
manager must:
(1) ensure that the service
planning team meets in person or by videoconferencing to develop:
(A) a proposed enrollment IPC, a PAS/HAB
plan, IPPs, and an HHSC IPP Addendum form for the individual in accordance with
§259.65 of this division (relating to Development of an Enrollment IPC);
and
(B) an individual
transportation plan, if transportation as a habilitation activity or as an
adaptive aid is included on the proposed enrollment IPC; and
(2) submit the documents described
in paragraph (1) of this subsection to HHSC for review in accordance with
§259.65 of this division.
(n) HHSC reviews a proposed enrollment IPC in
accordance with §259.69 of this division (relating to HHSC's Review of a
Proposed Enrollment IPC) to determine if:
(1)
the proposed enrollment IPC has an IPC cost at or below the amount in §
259.51(a)(4) of
this subchapter; and
(2) the CLASS
Program services and CFC services specified in the proposed enrollment IPC meet
the requirements described in §259.65(a)(1)(E)(iii) or (iv) and
§259.65(b) of this division.
(o) A CMA and DSA must not provide a CLASS
Program service or CFC service to an individual before HHSC notifies the CMA,
in accordance with §259.69(c)(1) of this division, that the individual's
request for enrollment into the CLASS Program has been approved. If a CMA or
DSA provides CLASS Program services or CFC services to an individual before the
effective date of the individual's enrollment IPC authorized by HHSC, HHSC does
not reimburse the CMA or DSA for those services.
(p) If HHSC notifies a CMA in accordance with
§259.69(c)(1) of this division that an individual's request for enrollment
is approved:
(1) the CMA must ensure the case
manager complies with §259.69(c)(2) of this division; and
(2) the CMA and DSA must comply with
§259.69(g) of this division.
(q) If HHSC notifies a CMA in accordance with
§259.69(e) of this division that an individual's request for enrollment
into the CLASS Program is approved, but action is being taken by HHSC to deny a
CLASS Program service or CFC service and modify the proposed enrollment IPC:
(1) the CMA must comply with §259.69(f)
of this division; and
(2) the CMA
and DSA must comply with §259.69(g) of this division.
