2400, Denial, Reduction, Suspension and Termination

Revision 17-1; Effective November 1, 2017

An individual whose CLASS program or CFC services are denied, reduced, suspended or terminated must be given notice of adverse actions taken by HHSC and is entitled to a fair hearing.

The CMA must obtain written authorization from HHSC for all suspensions of CLASS program or CFC services.

HHSC issues a notice to the CMA of all denials of enrollment or terminations from the CLASS program. The CMA must notify the individual, DSA, FMSA, CFS and SFS provider as applicable.

Program services may be terminated if the individual does not comply with the conditions as outlined in 40 TAC Section 45.406 or violates any of the conditions specified in 40 TAC Section 45.408. Program services may also be terminated if an individual does not comply with 40 TAC §45.407, or exhibits behavior that places the health and safety of the CMA's case manager or a DSA's service provider in immediate jeopardy as described in 40 TAC Section 45.409.

2410 Denial

Revision 17-1; Effective November 1, 2017

Denial is a HHSC action that disallows:

  • an individual's request for enrollment in the CLASS program;
  • a service requested on the IPC that was not authorized on the prior IPC; or
  • a portion of the amount or level of the service requested on the IPC that was not authorized on the prior IPC.

Denial of a Request for Enrollment into the CLASS Program

HHSC denies an individual's request for enrollment into the CLASS program if:

  • the individual does not meet the eligibility criteria described in Section 45.201, Eligibility Criteria; or
  • the DSAs serving the catchment area in which the individual resides are not willing to provide CLASS program services to the individual because they have determined that they cannot ensure the individual's health and safety.

If HHSC denies a request for enrollment, HHSC sends a written notice to the individual or LAR of the denial of the individual's request for enrollment into the CLASS program and includes in the notice the individual's right to request a fair hearing in accordance with 40 TAC Section 45.301, Individual's Right to a Fair Hearing. HHSC sends a copy of the written notice to the individual's DSA, CMA and, if selected, FMSA.

Denial of a CLASS Program Service

HHSC denies a CLASS program service on an individual's IPC if services:

  • are not necessary to protect the individual's health and welfare in the community;
  • do not address the individual's related condition;
  • are available to the individual through any other source including the Medicaid State Plan, other governmental programs, private insurance or the individual's natural supports;
  • do not prevent the individual's admission to an institution;
  • are not the most appropriate type and amount of CLASS program and CFC services to meet the individual's needs; or
  • are not cost effective.

If HHSC denies a CLASS program or CFC service on an individual's IPC, HHSC notifies the CMA in writing. Upon receipt of HHSC written notice of denial of a CLASS program or CFC service, the CMA must send Form 3624, Termination, Reduction or Denial of CLASS, to the individual/LAR of the denial of the service, copying the individual's DSA and, if selected, FMSA, CFS or SFS provider.

Form Resources

The following forms may need to be completed as part of a suspension denial of services:

Submission Standard

The following submission standards apply when submitting a request for an appeal to HHSC:

  • Form 3624, Termination, Reduction or Denial of CLASS
  • Written documentation established by the CMA in the event of a verbal request for appeal by individual/LAR (only if individual/LAR did not exercise their appeal rights using Form 3624)
  • Form 4800-D, Fair Hearing Request Summary
  • Form 4800-DA, 4800-D Addendum (only if there are more than three other hearing participants who require notification of a hearing)

2420 Reduction

Revision 17-1; Effective November 1, 2017

Reduction is an HHSC action taken because of a review of an IPC that decreases the amount or level of a service authorized by HHSC on an IPC.

HHSC will perform utilization review on all IPCs that meet criteria outlined in Section 5000, Utilization Review (UR). All services and units of service included on a proposed IPC must be justified by the SPT.

HHSC CLASS Program staff review the IPC to ensure the services on the IPC:

  • are necessary to protect the individual's health and welfare in the community;
  • supplement rather than replace the individual's natural supports and other non-CLASS program services and supports for which the individual may be eligible;
  • prevent the individual's admission to an institution;
  • are the most appropriate type and amount of services to meet the individual's needs; and
  • are cost effective.

The case manager has the responsibility to gather the following information for the HHSC CLASS program staff:

  • assessments;
  • reports;
  • professional observations; or
  • other resources.

The case manager must summarize this information using the appropriate IPP.

As necessary during the review of a proposed IPC, HHSC CLASS program staff will ask case managers to provide additional justification if the initial information submitted with a proposed IPC is not sufficient to demonstrate the need for requested services or does not meet requirements for a CLASS IPC as outlined in Section 1000, Introduction. If information submitted to HHSC by the case manager does not provide sufficient information to justify requested units of services, HHSC will modify the IPC by reducing the number of units of services as necessary and will send the CMA a copy of the modified IPC.

If an individual's services are reduced, the CMA must notify the individual and provide a copy of the notification to the DSA, FMSA and Support Family Services provider, as applicable, of the documentation of the reason for the reduction. Upon receipt of a written notice proposing to reduce a service, the CMA must inform the individual or LAR of the HHSC decision. The CMA informs the individual of the right to request a fair hearing.

The case manager sends written notice on Form 3624, Termination, Reduction or Denial of CLASS, to the individual allowing 12 days for the participant individual to respond before taking any action to reduce services.

If the individual or LAR requests a fair hearing before the effective date of the reduction of a CLASS program 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.

Form Resources

The following forms may need to be completed as part of a suspension reduction of services:

Submission Standard

The following submission standards apply when submitting a request for an appeal to HHSC:

  • Form 3624, Termination, Reduction or Denial of CLASS
  • Written documentation established by the CMA in the event of a verbal request for appeal by individual/LAR (only if individual/LAR did not exercise their appeal rights using Form 3624)
  • Form 4800-D, Fair Hearing Request Summary
  • Form 4800-DA, 4800-D Addendum (only if there are more than three other hearing participants who require notification of a hearing)

2430 Suspension

Revision 17- 1; Effective November 1, 2017

Individuals may not receive CLASS program or CFC services during a period of time in which they are admitted to a facility listed in this section. Individuals must be suspended without prior notification from CLASS program or CFC services until such time as the individual returns to his own or family home or is terminated from the CLASS program. The individual is not eligible for continuation of CLASS program or CFC services until the fair hearing process is completed because suspension of an individual's services is effective the date the individual was temporarily admitted to one of the facilities listed below, or leaves the state and, therefore, the individual is not given advance notice of the suspension.

Within two business days after the CMA becomes aware of a situation that necessitates an individual's CLASS program or CFC services to be suspended, the CMA must send a written request for suspension with written supporting documentation to HHSC CLASS program staff.

HHSC notifies the individual's CMA in writing of whether it authorizes a suspension of CLASS program or CFC services. Suspension is a HHSC action taken:

  • upon an individual's admission for any length of time up to 180 consecutive calendar days to one of the following facilities:
    • an ICF/IID licensed or subject to being licensed in accordance with Texas Health and Safety Code, Chapter 252, or certified by HHSC, unless the individual is receiving out-of-home respite in the facility;
    • a nursing facility licensed or subject to being licensed in accordance with Texas Health and Safety Code, Chapter 242, unless the individual is receiving out-of-home respite in the facility;
    • an assisted living facility licensed or subject to being licensed in accordance with Texas Health and Safety Code, Chapter 247;
    • a residential child-care operation licensed or subject to being licensed by the Texas Department of Family and Protective Services (DFPS), unless it is a foster family home or a foster group home;
    • a facility licensed or subject to being licensed by the Texas Department of State Health Services (DSHS);
    • a facility operated by HHSC; or
    • a residential facility operated by the Texas Youth Commission, a jail or prison; or
  • upon an individual leaving the state for up to 180 consecutive calendar days, except when an individual is receiving certain services available through the CDS option while the individual is temporarily staying at a location outside the state of Texas. For more details, see Information Letter No. 16-35, Receiving Services Outside the State of Texas in the CLASS and DBMD Programs.

Upon receipt of a written notice from HHSC authorizing the suspension of CLASS program or CFC services, the CMA must send the written notice of suspension to the individual/ LAR, DSA and FMSA, if applicable. The written notice includes the individual's right to request a fair hearing. The period of suspension is the length of the admission to the facility or the time spent in another state. An individual may remain on suspension from CLASS program or CFC services for up to 180 calendar days. HHSC may extend an individual's suspension for 30 calendar days upon the CMA's request.

Form Resources

The following forms may need to be completed as part of a suspension of services:

Submission Standard

The following submission standards apply when submitting a request for an appeal to HHSC:

  • Form 3624, Termination, Reduction or Denial of CLASS
  • Written documentation established by the CMA in the event of a verbal request for appeal by individual/LAR (only if individual/LAR did not exercise their appeal rights using Form 3624)
  • Form 4800-D, Fair Hearing Request Summary
  • Form 4800-DA, 4800-D Addendum (only if there are more than three other hearing participants who require notification of a hearing)

2440 Termination

Revision 17-1; Effective November 1 , 2017

Termination is a HHSC action that results in the loss of the individual's authorized services in the CLASS program and CFC.

2441 Termination With Advanced Notice

Revision 17- 1; Effective November 1, 2017

HHSC terminates an individual's CLASS program and CFC services if:

  • the individual does not meet program eligibility criteria;
  • the individual is admitted for more than 180 consecutive calendar days to one of the following facilities:
    • an ICF/IID licensed or subject to being licensed in accordance with Texas Health and Safety Code, Chapter 252 or certified by HHSC, unless the individual is receiving out-of-home respite in the facility;
    • a nursing facility licensed or subject to being licensed in accordance with Texas Health and Safety Code, Chapter 242, unless the individual is receiving out-of-home respite in the facility;
    • an assisted living facility licensed or subject to being licensed in accordance with Texas Health and Safety Code, Chapter 247;
    • 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;
    • a facility licensed or subject to being licensed by DSHS ;
    • a facility operated by HHSC;
    • a residential facility operated by the Texas Juvenile Justice Department, a jail or prison; or
  • the individual leaves the state for more than 180 consecutive calendar days and HHSC has not extended the individual's suspension;
  • DSAs serving the catchment area in which the individual resides are not willing to provide CLASS program and CFC services to the individual because they have determined that they cannot ensure the individual's health and safety; or
  • the individual refuses to comply with a mandatory participation requirement as follows:
    • not completing and submitting an application for Medicaid financial eligibility to HHSC within 30 calendar days after the case manager's initial face-to-face, in-home visit. (Note: If an individual or LAR does not submit a Medicaid application to HHSC within 30 calendar days of the case manager's initial face-to-face, in-home visit as required but is making good faith efforts to complete the application, the CMA may extend this time frame in 30 calendar-day increments as approved by HHSC CLASS program staff.);
    • not participating with the SPT to:
      • develop an enrollment IPC;
      • develop, renew, or revise an IPP-A;
      • renew and revise the IPC and IPPs;
    • not reviewing, agreeing to, signing and dating an IPC, IPP-A, and IPPs;
    • not using natural supports and other non-CLASS program or CFC services and supports for which the individual may be eligible before using CLASS program services;
    • not cooperating with the CMA and DSA in the delivery of CLASS program and CFC services listed on the individual's IPC, including:
      • working with the CMA and DSA in scheduling meetings;
      • attending scheduled meetings with the case manager or service provider;
      • being available to receive the CLASS program or CFC services;
      • notifying the CMA or DSA in advance if the individual or LAR is unable to attend a scheduled meeting or is unavailable to receive services in the individual's own or family home;
      • admitting CMA and DSA representatives to the individual's own home or family home for a scheduled meeting or to receive CLASS program and CFC services;
    • not cooperating with the CLASS program or CFC service providers to ensure progress toward achieving the goals and objectives described in the IPP for each CLASS program or CFC service listed on the IPC;
    • not paying a required copayment in a timely manner when found by HHSC to be financially eligible for CLASS program and CFC services based on the special institutional income limit;
    • not completing the procedures for redetermining eligibility for Medicaid, as described in the Medicaid for the Elderly and People with Disabilities Handbook;
    • engaging in criminal behavior in the presence of the case manager or CLASS program or CFC service provider;
    • permitting a person present in the individual's own or family home to engage in criminal behavior in the presence of the service provider or case manager;
    • acting in a manner that is threatening to the health and safety of the case manager or CLASS program or CFC service provider;
    • permitting a person present in the individual's own or family home to act in a manner that is threatening to the health and safety of the case manager or CLASS program or CFC service provider;
    • exhibiting behavior or permitting a person present in the individual's residence to exhibit behavior that places the health and safety of the case manager or CLASS program or CFC service provider in immediate jeopardy;
    • initiating or participating in fraudulent health care practices;
    • engaging in behavior that endangers the individual's health or safety; and
    • permitting a person present in the individual's own home or family home to engage in behavior that endangers the individual's health or safety.

If termination of services is requested based on a determination by the DSA that it cannot ensure the individual's health and safety, the CMA must include in the request specific reason(s) why the DSA determines it cannot ensure the individual's health and safety.

Prior to termination of services, an individual may choose another DSA. The CMA must provide the most current selection determination document in catchment areas with multiple DSAs. If another DSA determines the individual’s medical and nursing needs can be adequately met, the CMA must initiate a transfer IPC as described in Section 2340 of the CLASS Provider Manual.

HHSC notifies the individual's CMA in writing using Form 3624, Termination, Reduction or Denial of CLASS, or written notice from HHSC, of whether it authorizes the proposed termination of CLASS program and CFC services.

Upon receipt of HHSC notification authorizing a proposed termination of CLASS program services, the CMA must send written notice of the termination of CLASS program and CFC services to the individual or LAR within two business days. The CMA must send a copy of the termination notice to the individual's DSA and, if selected, FMSA, CFS and SFS provider. The CMA must include in the notice the individual's right to request a fair hearing.

In the event CLASS program services are terminated due to an individual's IPC cost being over $114,736.07, HHSC sends written notice to the individual or LAR of the proposal to terminate CLASS program services and includes the individual's right to request a fair hearing in the notice. HHSC sends a copy of the written notice to the individual's DSA, CMA, and if selected, FMSA.

If a CMA becomes aware an individual has not complied with a mandatory participation requirement described in this section, the CMA must immediately attempt to resolve the situation, including facilitating at least one face-to-face meeting with the SPT. If, after making attempts to resolve the situation, the CMA determines that the situation cannot be resolved, the CMA must request in writing that HHSC terminate CLASS program services for the individual. The request must be sent to HHSC within two business days of the CMA's determination the situation cannot be resolved and be supported by written documentation. The written documentation must include a description of:

  • the situation that resulted in the request to terminate CLASS program and CFC services; and
  • the attempts by the CMA and DSA to resolve the situation, including face-to-face meetings with the individual or LAR.

If an individual's CLASS Program services and CFC services are terminated, the CMA must ensure that the case manager informs the individual of alternative long-term care services and supports in the community. The explanation must include advising the individual about receiving CFC services through a managed care organization and institutional services, such as an ICF/IID. More information can be located on the Texas Health and Human Services website.

The CMA will not provide notice of a termination of CLASS program and CFC services to an individual for whom HHSC has terminated due to an IPC cost being over $114,736.07. HHSC will provide notice to individuals in this situation directly.

If the individual or LAR requests a fair hearing before the effective date of a proposed termination of CLASS program services, the DSA must provide services to the individual in the amounts authorized in the IPC while the appeal is pending.

2442 Termination Without Advanced Notice

Revision 17- 1; Effective November 1, 2017

HHSC terminates an individual's CLASS program services without advanced notice if any of the following situations exist:

  • the CMA or DSA has factual information confirming the death of the individual;
  • the CMA or DSA receives a clearly written statement signed by the individual that the individual no longer wishes to receive CLASS program services;
  • the individual's whereabouts are unknown and the post office returns mail directed to him or her by the CMA or DSA, indicating no forwarding address;
  • the CMA or DSA establishes the individual has been accepted for Medicaid services by another state; or
  • an individual or a person in the individual's residence exhibits behavior that places the health and safety of the CMA's case manager or a DSA's service provider in immediate jeopardy. See Section 2443, Immediate Jeopardy of CLASS Providers.

Within two business days after the CMA becomes aware of a situation such as described above, the CMA must send a written request to terminate CLASS program and CFC services to HHSC. The written request must be accompanied by documentation supporting the request.

If an individual's CLASS Program services and CFC services are terminated, the case manager must document attempts to inform the individual of alternative long-term care services and supports in the community. The explanation must include advising the individual about receiving CFC services through a managed care organization and institutional services, such as an ICF/IID. More information can be located on the Texas Health and Human Services website at https://hhs.texas.gov/.

HHSC notifies the individual's CMA in writing of whether it authorizes the termination of CLASS program services. Upon receipt of a written notice from HHSC authorizing the termination of CLASS program services, the CMA must send written notice to the individual or LAR of the termination. The CMA must also send a hard copy of the termination notice to the individual's DSA and, if selected, FMSA, CFS and SFS provider. The CMA must include in the notice the individual's right to request a fair hearing.

2443 Immediate Jeopardy of CLASS Providers

Revision 17-1; Effective November 1, 2017

HHSC may terminate an individual's CLASS program services if an individual or a person in the individual's residence exhibits behavior that places the health and safety of the CMA's case manager or a DSA's service provider in immediate jeopardy.

If a CMA or DSA becomes aware a situation exists that places the health and safety of the individual's case manager, CLASS program or CFC service provider in immediate jeopardy, the CMA or DSA must:

  • immediately file a report with the appropriate law enforcement agency and, if appropriate, make an immediate referral to DFPS; and
  • notify HHSC, CMA and DSA by telephone of the situation no later than one business day after the CMA or DSA becomes aware of the situation.

The CMA and DSA must attempt to resolve the situation. If, after making attempts to resolve the situation, the CMA determines that the situation cannot be resolved, the CMA must, within two business days after the CMA becomes aware of the situation, send a written request to terminate CLASS program and CFC services to HHSC. The written request must be accompanied by:

  • a description of the situation that resulted in the request to terminate the individual's CLASS program and CFC services;
  • a detailed description of the attempts by the CMA to resolve the situation; and
  • if available, a copy of any report issued by a law enforcement agency or DFPS regarding the situation.

HHSC notifies the individual's CMA in writing of whether it authorizes the proposed termination of CLASS program services.

Upon receipt of written notice from HHSC authorizing the termination of CLASS program services, the CMA must, no later than the date of the termination of services, send written notice to the individual or LAR of such termination. The CMA must provide a hard copy of the termination notice to the individual's DSA and, if selected, FMSA, CFS and SFS provider. The CMA must include in the notice the individual's right to request a fair hearing.

If an individual's CLASS Program services and CFC services are terminated, the case manager must document attempts to inform the individual of alternative long-term care services and supports in the community. The explanation must include advising the individual about receiving CFC services through a managed care organization and institutional services, such as an ICF/IID. More information can be located on the HHS website.

The CMA and DSA must maintain documentation of completion of these requirements in the individual's record.

Form Resources

The following forms may need to be completed as part of termination of services:

Submission Standard — Termination

The following submission standards apply when submitting termination paperwork to HHSC:

  • Form 3621, CLASS/CFC – Individual Plan of Care
  • Form 3624, Termination, Reduction or Denial of CLASS
  • Documentation of circumstances that support the termination of CLASS services.

Submission Standard — Appeal

The following submission standards apply when submitting a request for an appeal to HHSC:

  • Form 3624, Termination, Reduction or Denial of CLASS
  • Written documentation established by the CMA in the event of a verbal request for appeal by individual/LAR (only if individual/LAR did not exercise their appeal rights using Form 3624)
  • Form 4800-D, Fair Hearing Request Summary
  • Form 4800-DA, 4800-D Addendum(only if there are more than three other hearing participants who require notification of a hearing)