SECTION 259.83. Utilization Review of an IPC by HHSC

(a) At HHSC's discretion, HHSC conducts a utilization review of an IPC to determine if:

(1) the IPC cost is 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) or (iv) and §259.65(b) of this subchapter (relating to Development of an Enrollment IPC).

(b) If requested by HHSC, a program provider must submit documentation supporting an IPC to HHSC no later than 10 calendar days after HHSC's request.

(c) If HHSC determines that an IPC does not have an IPC cost at or below the amount in §259.51(a)(4) of this subchapter, HHSC notifies the individual's CMA and DSA of such determination and sends written notice to the individual or LAR that the individual's CLASS Program services and CFC services are proposed for termination and includes in the notice the individual's right to request a fair hearing in accordance with §259.101 of this chapter (relating to Individual's Right to a Fair Hearing).

(d) HHSC denies or proposes reduction of a CLASS Program service or CFC service if HHSC determines that an IPC has an IPC cost at or below the amount in §259.51(a)(4) of this subchapter but one or more of the CLASS Program services or CFC services specified in the IPC do not meet the requirements described in §259.65(a)(1)(E)(iii) or (iv) and §259.65(b) of this subchapter.

(e) If HHSC denies or proposes reduction of a CLASS Program service or CFC service, as described in subsection (d) of this section, HHSC:

(1) modifies and authorizes the IPC; and

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

(f) If HHSC notifies a CMA of the denial or proposed reduction of an individual's CLASS Program services or CFC services and of the IPC modified in accordance with subsection (e) of this section:

(1) for a denial of a CLASS Program service or CFC service:

(A) the CMA must comply with §259.155(c) of this chapter (relating to Denial of a CLASS Program Service or CFC Service); and

(B) the CMA and DSA must comply with §259.155(d) of this chapter; or

(2) for a proposed reduction of a CLASS Program service or CFC service:

(A) the CMA must comply with §259.159(c) and (e) of this chapter (relating to Reduction of a CLASS Program Service or CFC Service); and

(B) the DSA must comply with §259.159(d) and (e) of this chapter.

(g) The IPC period of an enrollment IPC or a renewal IPC modified by HHSC in accordance with subsection (e) of this section does not change as a result of HHSC's modification.

Source Note: The provisions of this §259.83 adopted to be effective January 30, 2023, 48 TexReg 362