Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 263 - HOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) › Subchapter B - ELIGIBILITY, ENROLLMENT, AND REVIEW › Section 263.101 - Eligibility Criteria for HCS Program Services and CFC Services

Current through Reg. 49, No. 28; July 12, 2024
(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:
(A) a hospital;
(B) an ICF/IID;
(C) a nursing facility;
(D) an ALF;
(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.