SECTION 260.83. Denial of Request for Enrollment in the DBMD Program or of a DBMD Program Service or a CFC Service

(a) Denial of an Individual's Request for Enrollment.

(1) HHSC denies an individual's request for enrollment in the DBMD Program if:

(A) the individual does not meet the eligibility criteria described in §260.51(a) of this subchapter (relating to Eligibility Criteria for DBMD Program Services and CFC Services);

(B) the individual or LAR fails to submit a completed Medicaid application to HHSC within one calendar year after the date of the case manager's initial in-person visit in the individual's residence; or

(C) the individual cannot obtain services from at least one program provider.

(2) HHSC sends a written notice of denial for enrollment in the DBMD Program to the program provider that the program provider, upon receipt, must send to the individual or LAR, copying the FMSA if applicable.

(3) If the individual or LAR requests a fair hearing, the program provider is not required to provide services to the individual while the appeal is pending.

(b) Denial of a DBMD Program service or a CFC Service.

(1) HHSC denies a DBMD Program service or a CFC service requested on the individual's IPC if HHSC determines, following utilization review conducted as described in §260.75 of this subchapter (relating to Utilization Review of an IPC by HHSC), that the service does not meet the requirements described in §260.67(a)(1) and (b) of this subchapter (relating to Development of a Proposed Enrollment IPC).

(2) HHSC sends a written notice with the effective date of the denial to the program provider that the program provider, upon receipt but no later than 12 calendar days before the effective date of denial, must send to the individual or LAR, copying the FMSA, if applicable.

(3) If the service denied by HHSC is requested:

(A) on an enrollment IPC submitted by the program provider in accordance with §260.61 of this subchapter (relating to Process for Enrollment of an Individual) and the individual or LAR requests a fair hearing, the program provider is not required to provide the service while the appeal is pending; or

(B) on a revision or renewal IPC submitted by the program provider in accordance with §260.77 of this subchapter (relating to Renewal and Revision of an IPP and IPC) and the individual or LAR requests a fair hearing before the effective date of denial specified in the written notice, the program provider:

(i) is not required to provide the service while the appeal is pending if the service was not authorized by HHSC on the prior IPC; or

(ii) must provide the service at the previously approved amount or level while the appeal is pending if the service was authorized by HHSC on the prior IPC.

Source Note: The provisions of this §260.83 adopted to be effective February 26, 2023, 48 TexReg 896