2200, Eligibility

Revision 17-1; Effective November 1, 2017

The case manager is responsible for verifying the individual's eligibility for the CLASS program by ensuring the following criteria are met.

  • The individual is financially eligible for Medicaid because the individual receives Supplemental Security Income (SSI) cash benefits or is determined by HHS to be financially eligible for Medicaid.
  • The individual has been diagnosed prior to age 22 with a related condition as described in the Texas Approved Diagnostic Codes for Persons with Related Conditions.
  • The individual has a qualifying adaptive behavior level of II, III, or IV (i.e., moderate to extreme deficits in adaptive behavior) obtained by administering a standardized assessment of adaptive behavior.
  • The individual demonstrates a need for CFC PAS/HAB;
  • The individual requires and receives:
    • at least one CLASS service per month; and
    • one CLASS service per year (monthly monitoring of services by a case manager meets this annual requirement).
  • The individual has an Individual Plan of Care (IPC) cost for CLASS services at or below $114,736.07.
  • The individual is not enrolled in another Medicaid waiver program.
  • The individual resides in his or her own home or family home.

The CMA must verify Medicaid eligibility each month by monitoring the Medicaid Eligibility Service Authorization Verification (MESAV) system. The Medicaid eligibility must verify the individual is eligible in the month that is being checked. Documentation of this monthly verification of eligibility for Medicaid must be maintained by the CMA and available for review during contract monitoring visits. If the CMA receives notice of an individual's impending loss of Medicaid eligibility, the CMA must work proactively with the individual/legally authorized representative (LAR) to ensure Medicaid eligibility is re-established as soon as possible. For individuals who lose Medicaid eligibility, the CMA must offer direct assistance to the individual/LAR as necessary to help the individual re-establish eligibility. The CMA must follow up with the individual/LAR at least every two weeks and document progress toward completion of necessary steps until Medicaid eligibility is re-established or the individual is terminated from the CLASS program.

Program services may be terminated if the individual does not meet any eligibility criteria as outlined in Title 40 of the Texas Administrative Code (TAC) §45.406. See Section 2400, Denial, Reduction, Suspension and Termination, for more information on termination of services.