5100, Overview

Revision 17-1; Effective November 1, 2017

At the Texas Health and Human Services Commission (HHSC)’s discretion, the Community Living Assistance and Support Services (CLASS) staff conducts UR of an Individual Plan of Care (IPC) to determine if:

  • the IPC meets the justification for services criterion as outlined in the CLASS/CFC program rules;
  • CLASS/CFC services as a whole enhance an individual's integration in the community and prevent admission to an institution while maintaining and improving independent functioning; and
  • the CLASS/CFC services specified in the IPC meet the following requirements:
      • are necessary to protect the individual's health and welfare in the community;
      • address the individual's related condition;
      • are not available to the individual through any other source, including the Medicaid state plan, other governmental programs, private insurance or the individual's natural supports;
      • are the most appropriate type and amount of CLASS/CFC program services to meet the individual's needs;
      • are cost effective;
      • meet the requirements relating to adaptive aids and minor home modifications, as outlined in Appendix I, Adaptive Aids and Appendix II, Minor Home Modification Services; and
      • is not receiving an excluded service as identified in Appendix III, Mutually Exclusive Services.

If requested by HHSC, a CLASS/CFC program provider must submit additional documentation supporting the IPC to HHSC within 10 calendar days after being requested.

If HHSC determines the IPC does not meet the justification for services criterion, HHSC:

  • notifies the individual's case management agency (CMA) and direct services agency (DSA) of such determination;
  • sends written notice to the individual or legally authorized representative (LAR) the individual's CLASS/CFC services are proposed for termination; and
  • includes in the notice the individual's right to request a fair hearing.

If HHSC determines one or more of the CLASS/CFC services specified in the IPC do not meet the requirements for an IPC, HHSC:

  • denies or reduces the service(s), as appropriate;
  • modifies and authorizes the IPC; and
  • notifies the individual's CMA, in writing, of the action taken.

If HHSC notifies the CMA of the denial or reduction of a CLASS/CFC service, see Section 2400, Denial, Reduction, Suspension and Termination.

If the individual or LAR requests a fair hearing before the effective date of the reduction of a CLASS/CFC service, as specified in the written notice, the DSA must provide the service to the individual in the amount authorized in the prior IPC while the appeal is pending.

The IPC effective period of an enrollment IPC or a renewal IPC modified by HHSC does not change as a result of HHSC' modification.

5200, CLASS Cost Limits

Revision 17-1; Effective November 1, 2017

This section describes utilization review (UR)  cost limits and service limits employed during review of a proposed IPC. HHSC may, at its discretion, select any proposed IPC for UR, regardless of total cost of services. HHSC selects a proposed IPC for UR at its discretion any time the agency receives a proposed IPC and will verify the IPC does not exceed the CLASS cost ceiling of $114,736.07. CLASS UR also verifies that CLASS services do not exceed a maximum combined cost of $10,000 for adaptive aids and dental treatment and $10,000 for minor home modifications. The IPC must not include more than 30 days of in-home respite and out-of-home respite combined. CFC services, which are subject to utilization review, are not included when verifying the cost ceiling is not surpassed.

As necessary, HHSC will coordinate with the individual's CMA to request additional justification information for proposed services and amounts of services included in an individual's proposed IPC as part of the UR process. The CMA is responsible to respond to HHSC’s UR requests in accordance with the CLASS rule in Title 40 of the Texas Administrative Code (TAC), §45.214. The CMA must submit any requested additional documentation supporting the proposed IPC to HHSC within 10 calendar days after HHSC’s request.

5300, Dental Utilization Review of Dental Services

Revision 17-1; Effective November 1, 2017

HHSC may choose to use a Texas licensed dentist to review a CLASS IPC that includes dental services to obtain needed expert opinion. HHSC staff may consult with a licensed dentist concerning dental services proposals if:

  • the cost of dental treatment exceeds a $2,000 limit;
  • a decision regarding medical need is required;
  • a determination regarding cost effectiveness is needed; or
  • a determination if the dental service requested is an allowable service.

The dentist identified by HHSC to perform dental UR may request additional items (e.g., x-rays, etc.) from the dentist who developed the dental treatment plan, as necessary. The HHSC dentist may contact the treating dentist by telephone, or by using secure e-mail if it is a matter of missing information or clarification. HHSC staff will keep a record of any additional information requested by the HHSC dentist to perform dental UR from the treating dentist, as well as the rationale provided by the HHSC dentist for denying or approving the request.
The HHSC dentist may make cost effectiveness determinations based on the most recently issued version of the Survey of Dental Fees published by the American Dental Association (ADA).