Current through Reg. 50, No. 13; March 28, 2025
(a) An applicant or
individual is eligible for HCS Program services if the applicant or individual:
(1) meets the financial eligibility criteria
as described in Appendix B of the HCS Program waiver application approved by
CMS and available on the HHSC website;
(2) meets one of the following criteria:
(A) based on a DID and as determined by HHSC
in accordance with §
263.105 of this subchapter
(relating to LOC Determination), qualifies for an ICF/IID LOC I, as defined in
§
261.238 of this title (relating to
ICF/MR Level of Care I Criteria);
(B) as determined by HHSC in accordance with
§
263.105 of this subchapter,
qualifies for an ICF/IID LOC I as defined in §
261.238 of this title or ICF/IID
LOC VIII, as defined in §
261.239 of this title (relating to
ICF/MR Level of Care VIII Criteria), and has been determined by HHSC:
(i) to have an intellectual disability or a
related condition;
(ii) to need
specialized services; and
(iii) to
be inappropriately placed in a Medicaid certified nursing facility based on an
annual resident review conducted in accordance with the requirements of Chapter
303 of this title (relating to Preadmission Screening and Resident Review
(PASRR); or
(C) meets
the following criteria:
(i) based on a DID
and as determined by HHSC in accordance with §
261.237 of this title (relating to
Level of Care) qualifies for one of the following levels of care:
(I) an ICF/IID LOC I as defined in §
261.238 of this title;
or
(II) an ICF/IID LOC VIII as
defined in §
261.239 of this title;
(ii) meets one of the following:
(I) resides in a nursing facility immediately
before enrolling in the HCS Program; or
(II) is at imminent risk of entering a
nursing facility as determined by HHSC; and
(iii) is offered HCS 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 HCS Program waiver application approved by CMS and available on the HHSC
website;
(3)
has an IPC cost that does not exceed:
(A)
$167,468 for an applicant or individual with an LON 1, LON 5, or LON
8;
(B) $168,615 for an applicant or
individual with an LON 6; or
(C)
$305,877 for an applicant or individual with an LON 9;
(4) 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 HCS Program as identified in the Mutually Exclusive Services
table in Appendix II of the HCS Handbook available on the HHSC
website;
(5) does not reside in:
(E) a residential child care facility
licensed by HHSC unless it is an agency foster home;
(F) an inpatient chemical dependency
treatment facility;
(G) a mental
health facility;
(H) a residential
facility operated by the Texas Workforce Commission; or
(I) a residential facility operated by the
Texas Juvenile Justice Department, a jail, or a prison; and
(6) requires the provision of:
(A) at least one HCS Program service per
month or a monthly monitoring visit by a service coordinator as described in
§
263.901(e)(40)
of this chapter (relating to LIDDA Requirements for Providing Service
Coordination in the HCS Program); and
(B) at least one HCS Program service per IPC
year.
(b) For
applicants or individuals with spouses who live in the community, the income
and resource eligibility requirements are determined according to the spousal
impoverishment provisions in §1924 of the Social Security Act and as
specified in the Medicaid State Plan.
(c) Except as provided in subsection (d) of
this section, an applicant or individual is eligible for a CFC service under
this chapter if the applicant or individual:
(1) meets the criteria described in
subsection (a) of this section;
(2)
requires the provision of the CFC service; and
(3) is not receiving host home/companion
care, supervised living, or residential support.
(d) To be eligible for a CFC service under
this chapter, an applicant or individual receiving MAO Medicaid must, in
addition to meeting the eligibility criteria described in subsection (c) of
this section, receive an HCS 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
§
263.901(e)(40)
of this chapter.
