3200, Eligibility

Revision 17-1; Effective November 1, 2017

The DSA is responsible for verifying the individual's eligibility for the CLASS program by ensuring the following criteria are met:

• the individual is determined by HHSC to meet the diagnostic and functional eligibility criteria for the CLASS program;
• 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 (ABL) 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 Program service per month, and one CLASS service per year (monthly monitoring of services by a case manager meets this requirement);
• the individual has an IPC cost for CLASS program services at or below $114,736.07;
• the individual is not enrolled in another Medicaid waiver program; and
• the individual resides in his own home or family home. Note: An individual is not considered to reside in his own home or family home if he is admitted to one of the facilities outlined in Section 2430, Suspension, and Section 3430, Suspension, for more than 180 consecutive calendar days.

Individuals who receive CLASS program and CFC services must maintain continuous eligibility as outlined above. The DSA must assess the individual at the time of enrollment, at least annually, and as necessary when an individual's situation changes that may result in the individual no longer meeting all CLASS eligibility criteria.

The DSA must verify Medicaid eligibility each month by monitoring the Medicaid Eligibility Service Authorization Verification (MESAV) system. The DSA 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 DSA and available for review by HHSC staff. If an individual is found to be ineligible for Medicaid, the DSA must notify the case manager no later than the next business day. The DSA must maintain verifiable evidence of notifying the case manager.

CLASS program and CFC services may be terminated if the individual does not meet all eligibility criteria as outlined in Title 40 of the Texas Administrative Code (TAC) §45.406. For more information regarding termination of services, see Section 3400, Denial, Reduction, Suspension and Termination.

See Appendix V, ID/RC Processing, for additional information and detailed instructions for DSAs.