SECTION 307.9. Individual Plan of Care (IPC)

(a) Each child and adolescent determined eligible to participate in the waiver program is assigned a mental health case manager, subject to the rules in Chapter 412, Subchapter I, of this title (relating to Mental Health Case Management Services). The mental health case manager must coordinate with the child or adolescent, LAR, waiver service providers and LMHA to develop an IPC that is based upon the assessment.

(b) The initial IPC must be reviewed by an LPHA at the LMHA that serves the geographic area of the participant's residence before forwarding to the department for approval. The IPC must be approved by the department before a provider can begin delivering waiver program services. To be approved, the IPC must:

(1) promote the child's or adolescent's inclusion into the community;

(2) protect the child's or adolescent's health and welfare in the community;

(3) supplement, rather than replace, the child's or adolescent's natural and other non-waiver program support systems and resources;

(4) be designed to prevent or reduce the likelihood of the child's or adolescent's admission to an inpatient psychiatric facility; and

(5) be the most appropriate type and amount of services to meet the child's or adolescent's needs.

(c) The IPC must be reviewed by an LPHA at the LMHA and submitted to the department for approval as part of the annual eligibility determination required under §419.3 of this title (relating to Eligibility Criteria). Any recommended changes to the IPC outside the annual review process must be approved by the department.

(d) To demonstrate that the waiver program services specified in the IPC meet the requirements described in subsection (b) of this section, the LMHA must submit the following to the department:

(1) an assessment of the child or adolescent that identifies and supports the waiver program services included in the IPC; and

(2) documentation that natural and other non-waiver program support systems and resources are unavailable or are insufficient to meet the goals specified in the IPC.

(e) The department may conduct utilization review of an IPC and supporting documentation at any time to determine if the services specified in the IPC meet the requirements described in subsection (b) of this section. If the department determines that one or more of the services specified in the IPC do not meet the requirements described in subsection (b) of this section, the department may deny, reduce, or terminate the service, modify the IPC, and send written notification to the child or adolescent, LAR, and the provider.

(f) In addition to the utilization review conducted in accordance with subsection (e) of this section, the department may conduct utilization review of the provider and the provision of waiver program services at any time.

(g) The cost of implementing the IPC must be within the cost ceiling identified by the department and the single state Medicaid agency. For children and adolescents with service needs that exceed the cost ceiling, the department has a process to ensure that their needs are met, which includes examining third-party resources or possible transition to other waiver programs or inpatient services.

Source Note: The provisions of this §307.9 adopted to be effective November 19, 2009, 34 TexReg 8038; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 471