SECTION 263.105. LOC Determination

(a) A LIDDA must request an LOC from HHSC for an applicant in accordance with this subsection.

(1) The LIDDA must complete an ID/RC Assessment for an applicant that:

(A) includes the LOC recommended by a person qualified to perform an initial evaluation of LOC in accordance with Appendix B of the HCS Program waiver application approved by CMS; and

(B) is signed and dated in accordance with the instructions for completing the ID/RC Assessment.

(2) The LIDDA must enter information from the completed ID/RC Assessment in the HHSC data system and electronically submit the information to HHSC.

(3) The LIDDA must ensure that the information entered in the HHSC data system and electronically submitted to HHSC is identical to the information on the completed ID/RC Assessment.

(4) The LIDDA must send a copy of the completed ID/RC Assessment and supporting documentation to HHSC, as requested by HHSC.

(b) A program provider must request an LOC for an individual from HHSC in accordance with this subsection.

(1) No more than 60 calendar days before the expiration date of an individual's ID/RC Assessment, a program provider must:

(A) complete an ID/RC Assessment that:

(i) includes the LOC recommended by a person qualified to perform a reevaluation of LOC in accordance with Appendix B of the HCS Program waiver application approved by CMS; and

(ii) is signed and dated by the program provider in accordance with the instructions for completing the ID/RC Assessment; and

(B) enter information from the completed ID/RC Assessment in the HHSC data system and electronically submit the information.

(2) A program provider must:

(A) ensure that the information entered and electronically submitted in the HHSC data system is identical to the information on the completed ID/RC Assessment;

(B) within three calendar days after entering and electronically submitting the information in the HHSC data system, provide the service coordinator with a copy of the completed ID/RC Assessment; and

(C) send a copy of the completed ID/RC Assessment and supporting documentation to HHSC, as requested by HHSC.

(3) If the program provider enters information from a completed ID/RC Assessment in the HHSC data system and electronically submits the information on a date that is more than 180 calendar days after the expiration date of the previous ID/RC Assessment, the program provider must:

(A) send to HHSC a copy of the completed ID/RC Assessment by a method, as instructed by HHSC, that:

(i) includes the recommended LOC; and

(ii) is signed and dated by the program provider in accordance with the instructions for completing the ID/RC Assessment;

(B) within three calendar days after sending the completed ID/RC Assessment to HHSC, provide the service coordinator with a copy of the completed ID/RC Assessment; and

(C) submit documentation supporting the ID/RC Assessment to HHSC, as requested by HHSC.

(c) For an LOC requested in accordance with subsection (b) of this section, within seven calendar days after a program provider enters information from a completed ID/RC Assessment in the HHSC data system and electronically submits the information, the service coordinator or a LIDDA representative other than the service coordinator must:

(1) review the information entered in the HHSC data system and electronically submitted, to determine if the information in the HHSC data system is identical to the information on the completed ID/RC Assessment the service coordinator received from the program provider;

(2) enter in the HHSC data system:

(A) the service coordinator's name and date of review; and

(B) one of the following:

(i) that the service coordinator agrees with the ID/RC Assessment, if the information in the HHSC data system is identical to the completed ID/RC Assessment; or

(ii) that the service coordinator disagrees with the ID/RC Assessment, if the information in the HHSC data system is not identical to the completed ID/RC Assessment; and

(3) if the service coordinator or a LIDDA representative other than the service coordinator enters in the HHSC data system that the service coordinator disagrees with the ID/RC Assessment, notify HHSC and the program provider of the service coordinator's disagreement in accordance with HHSC's instructions.

(d) For an LOC requested in accordance with subsection (b) of this section, HHSC considers a service coordinator's agreement or disagreement with an ID/RC Assessment in making an LOC determination.

(e) Information on an ID/RC Assessment must be supported by current data obtained from standardized evaluations and formal assessments that measure physical, emotional, social, and cognitive factors. A signed and dated ID/RC Assessment and documentation supporting the recommended LOC must be maintained in an individual's record.

(f) When HHSC receives a request for an LOC in accordance with subsection (a) or (b) of this section, HHSC determines if an applicant or individual qualifies for an LOC required by §263.101(a)(2) of this subchapter (relating to Eligibility Criteria for HCS Program Services and CFC Services).

(g) HHSC approves an LOC or sends a written notification:

(1) to the applicant, individual, or LAR that the applicant or individual is not eligible for HCS Program services or CFC services and provides the applicant, individual, or LAR with an opportunity to request a fair hearing in accordance with §263.801 of this chapter (relating to Fair Hearing);

(2) to the LIDDA that the LOC has been denied; and

(3) to the program provider using the HHSC data system that the LOC has been denied, if the applicant has selected a program provider or an individual is receiving services from a program provider.

(h) An LOC determination is valid for a period of time as described in this subsection.

(1) Except as provided in paragraph (2) of this subsection, an LOC determination is valid for a 365-calendar day period starting on the begin date of the ID/RC Assessment.

(2) If the begin date of the ID/RC Assessment is March 1 or later in a year before a leap year or January 1-February 28 of a leap year, the LOC determination is valid for a 366-calendar day period starting on the begin date of the ID/RC Assessment.

(i) An ID/RC Assessment submitted in accordance with subsection (b) of this section is effective on the date after the individual's previous ID/RC Assessment expires.

(j) If the LON of an individual receiving HCS Program services changes from a LON 5, LON 8, LON 6, or LON 9 to a LON 1, HHSC notifies the LIDDA of the change using the HHSC HCS Level of Care Redetermination Cover Sheet form.

(1) The LIDDA must, within 30 business days after receiving the notification:

(A) conduct a DID in accordance with §304.401 of this title (relating to Conducting a Determination of Intellectual Disability);

(B) complete the LIDDA section of the HHSC HCS Level of Care Redetermination Cover Sheet form, and return the form to HHSC; and

(C) submit a copy of the results of the new DID and any other pertinent information regarding the reassessment of the individual to HHSC.

(2) If the LIDDA is unable to complete the requirements described in paragraph (1) of this subsection within the 30-business day timeframe, the LIDDA must notify HHSC of the reasons for the delay.

(3) HHSC reviews the information submitted by the LIDDA regarding the redetermination and notifies the LIDDA and the HCS program provider of the review decision using the HHSC HCS Level of Care Redetermination Cover Sheet form.

(k) For an individual who is receiving all services through the CDS option and, therefore, does not have a program provider, the service coordinator:

(1) must perform the functions of the program provider described in subsection (b) of this section; and

(2) is not required to comply with subsection (c) of this section.

Source Note: The provisions of this §263.105 adopted to be effective March 1, 2023, 48 TexReg 1080