SECTION 259.69. HHSC's Review of a Proposed Enrollment IPC

(a) HHSC reviews a proposed enrollment IPC, a PAS/HAB plan, enrollment IPPs, an HHSC IPP Addendum form and, if required by §259.65(a)(1)(I) of this division (relating to Development of an Enrollment IPC), the individual transportation plan 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 (relating to Eligibility Criteria for CLASS Program Services and CFC Services); and

(2) the CLASS Program services and CFC services specified in the IPC meet the requirements described in §259.65(a)(1)(E)(iii) and (iv) and §259.65(b) of this division.

(b) At HHSC's request, a CMA must submit additional documentation supporting a proposed enrollment IPC to HHSC no later than 10 calendar days after HHSC's request.

(c) If HHSC determines that a proposed enrollment IPC meets the requirements described in subsection (a) of this section:

(1) HHSC notifies the CMA, in writing, that the individual's request for enrollment is approved; and

(2) as soon as possible, but no later than one business day after the CMA receives HHSC's notification, the case manager must:

(A) notify the individual or LAR of HHSC's approval of the request for enrollment;

(B) send a copy to the individual or LAR and to the DSA of:

(i) the enrollment IPC;

(ii) the PAS/HAB Plan;

(iii) the enrollment IPPs;

(iv) the HHSC IPP Addendum form;

(v) a service backup plan, if required by §259.65(a)(1)(H) of this division; and

(vi) the individual transportation plan, if required by §259.65(a)(1)(I) of this division; and

(C) if the individual will receive a service through the CDS option, send the FMSA a copy of the:

(i) enrollment IPC;

(ii) the PAS/HAB plan;

(iii) the enrollment IPPs;

(iv) the HHSC IPP Addendum form;

(v) a service backup plan, if required by §259.65(a)(1)(H) of this division; and

(vi) the individual transportation plan, if required by §259.65(a)(1)(I) of this division.

(d) If HHSC determines that a proposed enrollment IPC does not meet the requirements described in subsection (a)(1) of this section, HHSC:

(1) notifies the individual's CMA and DSA of such determination;

(2) sends written notice to the individual or LAR that the individual's request for enrollment is denied; and

(3) includes in the notice the individual's right to request a fair hearing in accordance with §259.101 of this subchapter (relating to Individual's Right to a Fair Hearing).

(e) If HHSC determines that a proposed enrollment IPC meets the requirement described in subsection (a)(1) of this section, but one or more of the CLASS Program services or CFC services specified in the IPC does not meet the requirements described in subsection (a)(2) of this section, HHSC:

(1) denies a CLASS Program service or CFC service;

(2) modifies and approves the proposed enrollment IPC;

(3) approves the individual's request for enrollment with the modified IPC; and

(4) notifies the individual's CMA, in writing, of the action taken.

(f) If HHSC notifies a CMA 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, as described in subsection (e) of this section, the CMA must comply with §259.155(c) of this chapter (relating to Denial of a CLASS Program Service or CFC Service).

(g) If HHSC approves an individual's request for enrollment, a CMA and DSA must:

(1) electronically access MESAV to determine if the information on an enrollment IPC or modified enrollment IPC is consistent with the information in MESAV;

(2) if the information on the enrollment IPC or modified enrollment IPC is inconsistent with the information in MESAV, notify HHSC of the inconsistency; and

(3) implement the enrollment IPC or modified enrollment IPC no later than seven calendar days after the effective date of the IPC.

Source Note: The provisions of this §259.69 adopted to be effective January 30, 2023, 48 TexReg 362