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§9.155: Eligibility Criteria and Suspension of Hcs Program Services

(a) An applicant or individual is eligible for HCS Program services if he or she:

(1) meets the financial eligibility criteria as defined in subsection (b) of this section;

(2) meets one of the following criteria:

(A) qualifies for the ICF/MR LOC I as defined in §9.238 of this chapter (relating to Level of Care I Criteria), as determined by DADS according to §9.161 of this subchapter (relating to LOC Determination); and

(i) has had a determination of mental retardation performed in accordance with state law (Texas Health and Safety Code, Chapter 593, Admission and Commitment to Mental Retardation Services, Subchapter A); or

(ii) has been diagnosed by a licensed physician as having a related condition as defined in §9.203 of this chapter (relating to Definitions) before enrollment in the HCS Program; or

(B) qualifies for the ICF/MR LOC I as defined in §9.238 of this chapter or ICF/MR LOC VIII as defined in §9.239 of this chapter (relating to ICF/MR Level of Care VIII Criteria), as determined by DADS according to §9.161 of this subchapter, and has been determined by DADS:

(i) to have mental retardation or a related condition;

(ii) to need specialized services; and

(iii) to be inappropriately placed in a Medicaid certified nursing facility based on an annual resident review conducted in accordance with the requirements of §19.2500 of this title (relating to Preadmission Screening and Resident Review (PASARR);

(3) has an authorized IPC for which the IPC cost does not exceed 200% of the annual ICF/MR reimbursement rate paid to a small ICF/MR, as defined in 1 TAC §355.456 (relating to Reimbursement Methodology) for the individual's level of need as it would be assigned under §9.240 of this chapter (relating to Level of Need) or 200% of the estimated annualized per capita cost for ICF/MR services, whichever is greater;

(4) is not enrolled in another waiver program under §1915(b) or (c) of the Social Security Act; and

(5) does not reside in:

(A) an ICF/MR licensed or subject to being licensed in accordance with Texas Health and Safety Code, Chapter 252, or certified by DADS;

(B) a nursing facility licensed or subject to being licensed in accordance with Texas Health and Safety Code, Chapter 242;

(C) an assisted living facility licensed or subject to being licensed in accordance with Texas Health and Safety Code, Chapter 247;

(D) a residential child-care operation licensed or subject to being licensed by DFPS unless it is a foster family home or a foster group home;

(E) a facility licensed or subject to being licensed by the Department of State Health Services (DSHS);

(F) a facility operated by DARS;

(G) a residential facility operated by the Texas Youth Commission, a jail, or a prison; or

(H) a setting in which two or more dwellings, including units in a duplex or apartment complex, single family homes, or facilities listed in subparagraphs (A) - (G) of this paragraph, excluding supportive housing under Section 811 of the National Affordable Housing Act of 1990, meet all of the following criteria:

(i) the dwellings create a residential area distinguishable from other areas primarily occupied by persons who do not require routine support services because of a disability;

(ii) most of the residents of the dwellings are persons with mental retardation; and

(iii) the residents of the dwellings are provided routine support services through personnel, equipment, or service facilities shared with the residents of the other dwellings.

(b) An applicant or individual is financially eligible for the HCS Program if he or she:

(1) is categorically eligible for SSI benefits;

(2) has once been eligible for and received SSI benefits and continues to be eligible for Medicaid as a result of protective coverage mandated by federal law;

(3) is under 18 years of age and:

(A) resides with a parent or spouse;

(B) is eligible for Medicaid benefits only, if institutionalized;

(C) meets the SSI criteria for disability;

(D) meets the SSI criteria for institutional deeming; and

(E) has income and resources that meet the requirements of the SSI program;

(4) is under 20 years of age and:

(A) is financially the responsibility of DFPS in whole or in part; and

(B) is being cared for in a foster home or group home:

(i) that is licensed or certified and supervised by DFPS or a licensed public or private nonprofit child placing agency; and

(ii) in which a foster parent is the primary caregiver residing in the home;

(5) is a member of a family who receives full Medicaid benefits as a result of qualifying for TANF; or

(6) is eligible for SSI benefits in the community, except on the basis of income, and meets the special institutional income limit for Medicaid benefits in Texas without regard to spousal income.

(c) For applicants or individuals with spouses who live in the community, the income and resource eligibility requirements are determined according to the spousal impoverishment provisions in §1924 of the Social Security Act and as specified in the Medicaid State Plan.

(d) If an individual is temporarily admitted to one of the following settings, the individual's HCS Program services are suspended during that admission:

(1) a hospital;

(2) an ICF/MR licensed or subject to being licensed in accordance with Texas Health and Safety Code, Chapter 252 or certified by DADS;

(3) a nursing facility licensed or subject to being licensed in accordance with Texas Health and Safety Code, Chapter 242;

(4) a residential child-care operation licensed or subject to being licensed by DFPS;

(5) a facility licensed or subject to being licensed by the DSHS;

(6) a facility operated by DARS; or

(7) a residential facility operated by the Texas Youth Commission, a jail, or a prison.

Comments

Source Note: The provisions of this §9.155 adopted to be effective March 1, 2000, 25 TexReg 1649; amended to be effective September 1, 2001, 26 TexReg 5823; amended to be effective September 1, 2003, 28 TexReg 6885; amended to be effective August 31, 2004, 29 TexReg 8333; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; amended to be effective June 1, 2006, 31 TexReg 4442; amended to be effective June 1, 2008, 33 TexReg 4334; amended to be effective June 1, 2010, 35TexReg 4441