SECTION 260.69. HHSC's Review of Request for Enrollment

(a) HHSC reviews a request for enrollment submitted by a case manager in accordance with §260.61(l)(1) of this division (relating to Process for Enrollment of an Individual) to determine if:

(1) the individual meets the requirements described in §260.51(a)(2) and (3) of this subchapter (relating to Eligibility Criteria for DBMD Program Services and CFC Services);

(2) the proposed enrollment IPC has a cost at or below the amount in §260.51(a)(4) of this subchapter;

(3) the goals and outcomes documented in the enrollment IPP for each DBMD Program service and CFC service, except for CFC support management, meet the criteria described in §260.65(b)(3) and (4) of this division (relating to Development of an Enrollment IPP);

(4) the DBMD Program services and CFC services, except for CFC support management, specified in the proposed enrollment IPC meet the requirements described in §260.67(a)(1) and (b) of this division (relating to Development of a Proposed Enrollment IPC);

(5) the individual is Medicaid-eligible due to receipt of Supplemental Security Income cash benefits or is determined by HHSC to be financially eligible for Medicaid; and

(6) the individual meets the requirement described in §260.51(a)(5) of this subchapter.

(b) To support the information in a proposed enrollment IPC and IPP, HHSC may request from a case manager a copy of the information described in §260.67(d) of this division.

(c) If HHSC requests the information described in subsection (b) of this section, a case manager must submit the information to HHSC no later than 10 calendar days after the date of the request.

(d) If HHSC determines that the individual's request for enrollment meets the requirements described in subsection (a) of this section:

(1) HHSC notifies the program provider, in writing, that the individual's request for enrollment into the DBMD Program is approved; and

(2) within 10 business days after receiving the written notice, the case manager must:

(A) provide to the individual or LAR a copy of the enrollment IPC, the IPP, and if required by §260.213 of this chapter (relating to Service Backup Plans), a service backup plan; and

(B) if the individual will receive a service through the CDS option, send the FMSA a copy of the enrollment IPC, the IPP, and if required by §260.61(k)(2)(J)(i) of this subchapter, the individual transportation plan.

(e) HHSC notifies the individual's program provider, in writing, that the individual's request for enrollment is denied if the request for enrollment does not meet the requirements described in subsection (a) of this section.

(f) If HHSC notifies a program provider that an individual's request for enrollment is denied, the program provider must send the individual or LAR written notice of the denial in accordance with §260.83(a) of this subchapter (relating to Denial of Request for Enrollment in the DBMD Program or of a DBMD Program Service or a CFC Service).

(g) If HHSC determines a DBMD Program service or CFC service specified in the proposed enrollment IPC does not meet the requirements described in §260.67(a)(1) and (b) of this division, HHSC:

(1) denies the service;

(2) modifies and approves the IPC;

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

(4) notifies the program provider, in writing, of the action taken.

(h) If HHSC notifies a program provider of the denial of a DBMD Program service or CFC service and of the modification of the proposed enrollment IPC in accordance with subsection (g) of this section, the program provider must:

(1) implement the modified enrollment IPC; and

(2) send the individual or LAR written notice of the denial of a DBMD Program service or a CFC service in accordance with §260.83(b) of this subchapter.

(i) If HHSC approves an individual's request for enrollment, a program provider must:

(1) electronically access MESAV to determine if the information on an 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.

(j) HHSC may approve the effective date of an IPC as requested on the proposed enrollment IPC or may modify the effective date.

(k) HHSC's determination that an individual meets the requirements described in §260.51(a)(2) and (3) of this subchapter and approval of the proposed enrollment IPC is valid for the IPC period of the enrollment IPC.

Source Note: The provisions of this §260.69 adopted to be effective February 26, 2023, 48 TexReg 896