26 Tex. Admin. Code § 259.79

Current through Reg. 49, No. 49; December 6, 2024

Section 259.79 - Renewal and Revision of an IPC

(a) Beginning the effective date of an individual's IPC, as determined by § 259.65(g) of this subchapter (relating to Development of an Enrollment IPC) or §259.77(b) of this division (relating to Renewal IPC and Requirement for Authorization to Continue Services), a case manager must, in accordance with the Community Living Assistance and Support Services Provider Manual:

(1) meet with the individual and LAR in person to conduct an IPP service review meeting at a time and place convenient to the individual and LAR; and

(2) at least once during an IPC period, conduct an IPP service review meeting in person with the individual and LAR in the individual's residence.

(b) During an IPP service review meeting described in subsection (a) of this section, a case manager must:

(1) review the individual's progress toward achieving the goals and outcomes as described on the IPP for each service listed on the individual's IPC;

(2) if the individual's IPC includes nursing or CFC PAS/HAB, and any of those services are not identified on the IPC as critical to meeting the individual's health and safety, discuss with the individual or LAR whether the service may now be critical to the individual's health and safety;

(3) if a service backup plan has been implemented, discuss the implementation of the service backup plan with the individual or LAR to determine whether or not the plan was effective;

(4) if the case manager determines that a service may now be critical to the individual's health and safety, as described in paragraph (2) of this subsection, or that the service backup plan was ineffective, as described in paragraph (3) of this subsection, document the determination for discussion at a service planning team meeting convened in accordance with subsection (c) or (d) of this section;

(5) complete the HHSC IPP Service Review form in accordance with the Community Living Assistance and Support Services Provider Manual; and

(6) ensure the individual or LAR signs and dates the HHSC IPP Service Review form.

(c) No more than 90 calendar days before the end of an individual's current IPC period, the case manager must convene a service planning team meeting in person or by videoconferencing in which:

(1) the service planning team:

(A) reviews the HHSC CLASS/DBMD Nursing Assessment form completed by an RN as described in §259.75(a)(1)(B) of this division (relating to Annual Review by HHSC of Whether an Individual Meets LOC VIII Criteria);

(B) addresses any information included in Addendum E of the HHSC CLASS/DBMD Nursing Assessment form, Recommendations/Coordination of Care, to ensure the individual's needs are met;

(C) documents on the HHSC CLASS/DBMD Coordination of Care form how the information in Addendum E of the HHSC CLASS/DBMD Nursing Assessment form was addressed;

(D) develops a proposed renewal IPC that:

(i) documents each CLASS Program service and CFC service, other than CFC support management, to be provided to the individual;

(ii) specifies the number of units of each CLASS Program service and CFC service, other than CFC support management, to be provided to the individual;

(iii) for each CLASS Program service:

(I) is within the service limit described in § 259.73 of this subchapter (relating to Service Limits);

(II) if an adaptive aid, meets the requirements in Subchapter F, Division 1, of this chapter (relating to Adaptive Aids); and

(III) if a minor home modification, meets the requirements in Subchapter F, Division 2, of this chapter (relating to Minor Home Modifications);

(iv) for CFC ERS, meets the requirements in Subchapter F, Division 3, of this chapter (relating to CFC ERS);

(v) states if the individual will receive CFC support management;

(vi) describes any other service or support to be provided to the individual through sources other than CLASS Program services or CFC services;

(vii) if the proposed renewal IPC includes nursing or CFC PAS/HAB, identifies whether the service is critical to the individual's health and safety, as required by § 259.89(a)(2) of this subchapter (relating to Service Backup Plans);

(viii) if the individual chooses to receive services through the CDS option, identifies:

(I) the name of the individual's FMSA; and

(II) the type and estimated units of each CLASS Program service and CFC service provided through the CDS option;

(E) develops a renewal IPP for each CLASS Program service and CFC service listed on the proposed renewal IPC, other than CFC support management, as required by § 259.67 of this subchapter (relating to Development of IPPs);

(F) develops a new HHSC IPP Addendum form;

(G) develops a new PAS/HAB plan based on review of the information obtained from assessments conducted and observations made by a DSA as required by § 259.61(h)(2) and (3) of this subchapter;

(H) if the proposed renewal IPC identifies nursing or CFC PAS/HAB as critical, develops or revises a service backup plan for the service in accordance with § 259.89 of this subchapter; and

(I) if transportation as a habilitation activity or as an adaptive aid is included on the proposed renewal IPC, develops a new individual transportation plan;

(2) the case manager:

(A) provides an oral and written explanation of the following to an individual and LAR or actively involved person:

(i) CLASS Program services;

(ii) CFC services;

(iii) the mandatory participation requirements 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 subchapter (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 described in 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; and

(x) how to contact the individual's case manager;

(B) provides an oral explanation to the individual and to the LAR or actively involved person that the individual, LAR, actively involved person may request:

(i) that the individual transfer to a different CMA, DSA, or FMSA at any time while enrolled in the CLASS Program;

(ii) that the DSA provide transportation as a habilitation activity, out-of-home respite in a camp described in § 259.361(b)(2)(D) of this chapter (relating to Respite and Dental Treatment), adaptive aids, nursing, or CFC PAS/HAB while the individual is temporarily 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; and

(iii) that the DSA provide transportation as a habilitation activity, out-of-home respite in a camp, adaptive aids, nursing, or CFC PAS/HAB as described in clause (ii) of this subparagraph more than once during an IPC period;

(C) uses 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 the following:

(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 to 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; and

(ii) that CLASS Program services or 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);

(D) gives the individual and the LAR or actively involved person a written list of CMAs and DSAs serving the catchment area in which the individual resides;

(E) has the individual or LAR select a CMA and DSA by completing an HHSC Selection Determination form as described in the Community Living Assistance and Support Services Provider Manual;

(F) educates the individual, LAR, and actively involved person about protecting the individual from abuse, neglect, and exploitation; and

(G) documents that the case manager complied with subparagraphs (A) - (F) of this paragraph; and

(3) a DSA staff person:

(A) provides an oral and written explanation of the following to the individual and LAR or actively involved person:

(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;

(iii) that the HHSC Complaint and Incident Intake toll-free telephone number at 1-800-458-9858 may be used to file a complaint; and

(iv) how to contact the DSA;

(B) educates the individual, LAR, and actively involved person about protecting the individual from abuse, neglect, and exploitation; and

(C) documents that the staff person complied with subparagraphs (A) and (B) of this paragraph.

(d) Except as provided in subsection (e) of this section, no later than five business days after becoming aware that an individual's need for a CLASS Program service or CFC service changes, the case manager must:

(1) convene a service planning team meeting in person or by videoconferencing in which the service planning team:

(A) develops a proposed revised IPC;

(B) if the proposed revised IPC includes nursing or CFC PAS/HAB:

(i) identifies whether the service is critical to the individual's health and safety, as required by § 259.89(a)(2) of this subchapter; and

(ii) develops a new or revised service backup plan for the service in accordance with § 259.89 of this subchapter;

(C) if the IPC is revised because the individual wants to receive a service through the CDS option, identifies on the proposed revised IPC:

(i) the name of the individual's FMSA; and

(ii) the type and estimated units of each CLASS Program service and CFC service the individual wants to receive through the CDS option;

(D) develops any revised IPPs;

(E) if the individual's needs have substantially changed, develops a revised HHSC IPP Addendum form;

(F) if the IPC needs to be revised to add CFC PAS/HAB or change the amount of CFC PAS/HAB, develops a new or revised PAS/HAB plan; and

(G) if transportation as a habilitation activity or as an adaptive aid is included on the proposed revised IPC, develops a new or revised individual transportation plan; and

(2) if the individual may need cognitive rehabilitation therapy, assist the individual to obtain an assessment as required by § 259.311(h) of this chapter (relating to CMA Service Delivery).

(e) If an individual receiving CFC PAS/HAB or the LAR requests CFC support management during an IPC year, the case manager must revise the IPC, as described in the Community Living Assistance and Support Services Provider Manual.

(f) A case manager must:

(1) ensure that a proposed renewal IPC or proposed revised IPC developed in accordance with subsection (c) or (d) of this section meets the requirements described in §259.65(a)(1)(E)(iii) or (iv) and § 259.65(b) of this subchapter; and

(2) ensure that a renewal IPP or revised IPP, developed in accordance with subsection (c) or (d) of this section, is reviewed, signed, and dated as evidence of agreement by:

(A) the individual or LAR;

(B) the case manager; and

(C) the DSA.

(g) If an individual or LAR, case manager, and DSA agree on the type and amount of services to be included in a proposed renewal IPC or proposed revised IPC developed in accordance with subsection (c) or (d) of this section, the case manager must:

(1) ensure that the proposed renewal IPC or proposed revised IPC is reviewed, signed, and dated as evidence of agreement by:

(A) the individual or LAR;

(B) the case manager; and

(C) the DSA;

(2) for a proposed renewal IPC, at least 30 calendar days before the end of the individual's IPC period:

(A) submit to HHSC for its review:

(i) the signed proposed renewal IPC;

(ii) the signed renewal IPPs;

(iii) the new HHSC IPP Addendum form;

(iv) the new PAS/HAB plan;

(v) the completed HHSC CLASS/DBMD Nursing Assessment form provided by the DSA in accordance with §259.75(a)(3) of this division;

(vi) the ID/RC Assessment authorized by HHSC;

(vii) the HHSC Non-Waiver Services form;

(viii) Choice Lists for the CLASS Program;

(ix) a service backup plan, if required by subsection (c)(1)(H) of this section;

(x) the new individual transportation plan, if required by subsection (c)(1)(I) of this section;

(xi) the HHSC Request for Adaptive Aids, Medical Supplies, Minor Home Modifications or Dental Services/Sedation form, if required by:

(I) § 259.255 of this chapter (relating to Requirements for Authorization to Purchase an Adaptive Aid Costing Less Than $500);

(II) § 259.257 of this chapter (relating to Requirements for Authorization to Purchase an Adaptive Aid Costing $500 or More);

(III) § 259.275 of this chapter (relating to Requirements for Authorization to Purchase a Minor Home Modification); and

(IV) § 259.361 of this chapter;

(xii) the HHSC Specifications for Adaptive Aids/Medical Supplies/Minor Home Modifications form, if required by:

(I) § 259.257 of this chapter; and

(II) § 259.275 of this chapter;

(xiii) denial documentation from non-waiver resources, if any; and

(xiv) if a skilled or a specialized therapy, the HHSC Therapy Justifications - Attachment to IPP form;

(B) send the DSA a copy of:

(i) the signed proposed renewal IPC;

(ii) the signed renewal IPPs;

(iii) the new HHSC IPP Addendum form;

(iv) the new PAS/HAB plan, if required by subsection (c)(1)(G) of this section;

(v) a service backup plan, if required by subsection (c)(1)(H) of this section; and

(vi) the new individual transportation plan, if required by subsection (c)(1)(I) of this section; and

(C) if the renewal IPC includes a service through the CDS option, send the FMSA a copy of:

(i) the signed proposed renewal IPC;

(ii) the signed renewal IPPs;

(iii) the new HHSC IPP Addendum form;

(iv) the new PAS/HAB plan, if required by subsection (c)(1)(G) of this section;

(v) a service backup plan, if required by subsection (c)(1)(H) of this section; and

(vi) the new individual transportation plan, if required by subsection (c)(1)(I) of this section; and

(3) for a proposed revised IPC, at least 30 calendar days before the effective date of the proposed revised IPC determined by the service planning team:

(A) submit to HHSC for its review:

(i) the signed proposed revised IPC;

(ii) the signed revised IPPs;

(iii) the revised HHSC IPP Addendum form, if required by subsection (d)(1)(E) of this section;

(iv) the HHSC Non-Waiver Services form;

(v) the completed HHSC CLASS/DBMD Nursing Assessment form;

(vi) a new or revised service backup plan, if required by subsection (d)(1)(B)(ii) of this section;

(vii) the new or revised PAS/HAB plan, if required by subsection (d)(1)(F) of this section;

(viii) the new or revised individual transportation plan, if required by subsection (d)(1)(G) of this section;

(ix) an HHSC Request for Adaptive Aids, Medical Supplies, Minor Home Modifications or Dental Services/Sedation form, if required by:

(I) § 259.255 of this chapter;

(II) § 259.257 of this chapter;

(III) § 259.275 of this chapter; and

(IV) § 259.361 of this chapter;

(x) an HHSC Specifications for Adaptive Aids/Medical Supplies/Minor Home Modifications form, if required by:

(I) § 259.257 of this chapter; and

(II) § 259.275 of this chapter;

(xi) denial documentation from non-waiver resources, if any; and

(xii) if a skilled or specialized therapy, the HHSC Therapy Justifications - Attachment to IPP form;

(B) send the DSA a copy of:

(i) the signed proposed revised IPC;

(ii) the signed revised IPPs;

(iii) the revised HHSC IPP Addendum form, if required by subsection (d)(1)(E) of this section;

(iv) the new or revised service backup plan, if required by subsection (d)(1)(B)(ii) of this section;

(v) the new or revised PAS/HAB plan, if required by subsection (d)(1)(F) of this section; and

(vi) the new or revised individual transportation plan, if required by subsection (d)(1)(G) of this section; and

(C) if the revised IPC includes a service through the CDS option, send the FMSA a copy of:

(i) the signed proposed revised IPC;

(ii) the signed revised IPPs;

(iii) the revised HHSC IPP Addendum form, if required by subsection (d)(1)(E) of this section;

(iv) the new or revised service backup plan, if required by subsection (d)(1)(B)(ii) of this section;

(v) the new or revised PAS/HAB plan, if required by subsection (d)(1)(F) of this section; and

(vi) the new or revised individual transportation plan, if required by subsection (d)(1)(G) of this section.

(h) If an individual or LAR requests a CLASS Program service or a CFC service that the case manager or DSA has determined does not meet the requirements described in §259.65(a)(1)(E)(iii) or (iv) or § 259.65(b) of this subchapter, the CMA must, in accordance with the Community Living Assistance and Support Services Provider Manual, send the individual or LAR written notice of the denial or proposed reduction of the requested CLASS Program service, copying the DSA and, if applicable, the FMSA.

(i) If a CMA is required to send a written notice of the denial or proposed reduction of a CLASS Program service or CFC service, as described in subsection (h) of this section, the CMA must:

(1) at least 30 calendar days before the end of the IPC period, submit to HHSC for its review:

(A) a proposed renewal IPC or proposed revised IPC that includes the type and amount of CLASS Program services or CFC services in dispute and not in dispute, and is signed and dated by:

(i) the individual or LAR;

(ii) the case manager; and

(iii) the DSA;

(B) the renewal IPPs;

(C) the new or revised HHSC IPP Addendum form;

(D) the new or revised PAS/HAB plan, if required by subsection (c)(1)(G) or (d)(1)(F) of this section; and

(E) the new or revised individual transportation plan, if required by subsection (c)(1)(I) or (d)(1)(G) of this section; and

(2) if the individual receives a service through the CDS option, send the FMSA a copy of the documents submitted to HHSC in accordance with paragraph (1) of this subsection.

(j) At HHSC's request, a CMA must submit additional documentation supporting a proposed renewal IPC or proposed revised IPC submitted to HHSC no later than 10 calendar days after the date of HHSC's request.

(k) If HHSC determines that a proposed renewal IPC or proposed revised IPC has an IPC cost at or below the amount in § 259.51(a)(4) of this subchapter and the CLASS Program services and CFC services specified in the IPC meet the requirements described in §259.65(a)(1)(E)(iii) or (iv) and § 259.65(b) of this subchapter:

(1) HHSC notifies the individual's CMA, in writing, that the renewal IPC or revised IPC is authorized;

(2) the CMA must send a copy of the authorized renewal or revised IPC to the DSA and, if the individual receives a service though the CDS option, to the FMSA; and

(3) the CMA and the DSA must:

(A) electronically access MESAV to determine if the information on the renewal or revised IPC is consistent with the information in MESAV;

(B) if the information on the renewal or revised IPC is inconsistent with the information in MESAV, notify HHSC of the inconsistency; and

(C) initiate CLASS Program services and CFC services for the individual in accordance with the individual's renewal or revised IPC no later than seven calendar days after the CMA receives HHSC's notification.

(l) If an individual's IPC period expires before HHSC approves a proposed renewal IPC:

(1) a CMA and DSA must continue to provide services to the individual until HHSC authorizes the proposed renewal IPC to ensure continuity of care and prevent the individual's health and welfare from being jeopardized; and

(2) if HHSC authorizes the proposed renewal IPC as described in subsection (k)(1) of this section, HHSC will reimburse the CMA and DSA for services provided, as required by paragraph (1) of this subsection, for a period of not more than 180 calendar days before the date HHSC receives the documentation described in subsection (i)(2) of this section from the DSA.

(m) The process by which an individual's CLASS Program services or CFC services are terminated or denied based on HHSC's review of a proposed renewal IPC or proposed revised IPC is described in §259.83(c) - (e) of this division (relating to Utilization Review of an IPC by HHSC).

(n) The IPC period of a revised IPC is the same IPC period as the enrollment IPC or renewal IPC being revised.

26 Tex. Admin. Code § 259.79

Adopted by Texas Register, Volume 48, Number 04, January 27, 2023, TexReg 0380, eff. 1/30/2023