3400, Denial, Reduction, Suspension and Termination

Revision 17-1; Effective November 1, 2017

An individual who has been denied enrollment or terminated from the CLASS program and CFC services, or an individual whose CLASS program and 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.

Program services may be terminated if the individual does not comply with the conditions as outlined in 40 TAC §45.406 or violates any of the conditions specified in 40 TAC §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 §45.409

3410 Denial

Revision 17-1; Effective November 1, 2017

Denial is an 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 a prior IPC; or
  • a portion of the amount or level of the service requested on the IPC that was not authorized on a prior IPC.

3411 Denial of a Request for Enrollment into the CLASS Program

Revision 17-1; Effective November 1, 2017

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

  • the individual does not meet the eligibility criteria described in §45.201, Eligibility Criteria; or
  • the 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 they cannot ensure the individual's health and safety.

If HHSC denies an individual's request for enrollment, HHSC sends 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 §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, Financial Management Services Agency (FMSA).

3412 Denial of a CLASS Program or CFC Service

Revision 17-1; Effective November 1, 2017

CLASS program and 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.

HHSC denies a CLASS program or CFC 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;
  • 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 determines one or more of the CLASS program or CFC services specified in the IPC do not meet the requirements for an IPC, HHSC:

  • for an enrollment IPC, approves enrollment in CLASS program with the modified IPC;
  • denies the CLASS program or CFC service(s), as appropriate;
  • modifies and authorizes the IPC;
  • sends a copy of the modified IPC to the CMA; and
  • notifies the individual's CMA, in writing, of the action taken.

Form Resources

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

3420 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 CLASS program or CFC services not authorized by HHSC on a prior IPC.

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

HHSC 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;
  • CLASS program and 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;
  • are the most appropriate type and amount of CLASS program and CFC services to meet the individual's needs; and
  • are cost effective.

As necessary during the review of a proposed IPC, HHSC 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 a proposed CLASS program and CFC service(s). If information submitted to HHSC by the case manager does not provide sufficient information to justify requested CLASS program and CFC services or amounts of CLASS program and CFC services, HHSC will reduce the number of units of CLASS program and CFC services, as necessary, and will send the CMA a copy of the modified IPC.

If an individual's services are reduced, CMA notifies the DSA in writing describing HHSC's reason for the reduction. The CMA also notifies the DSA if and when the individual chooses to appeal the decision. If the individual or LAR requests a fair hearing within 10 days from date of notification, 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 reduction of services:

3430 Suspension

Revision 17-1; Effective November 1, 2017

Suspension is an HHSC action that results in temporary loss of the individual's authorized CLASS program or CFC services. An individual may remain on suspension from CLASS for up to 180 calendar days. HHSC may extend an individual's suspension for 30 calendar days upon the CMA's request.

Suspension is an HHSC action taken because of:

  • an individual's admission, for up to180 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;
    • a residential facility operated by the Texas Youth Commission; or
    • a jail or prison;
  • an individual leaving the state for up to 180 consecutive calendar days, except for individuals receiving certain services available through the CDS option while the individual is temporarily staying at a location outside the state of Texas. For more information, see Information Letter No. 16-35, Receiving Services Outside the State of Texas in the CLASS and DBMD Programs.

Within two business days of learning of a situation that necessitates an individual's CLASS program and CFC services to be suspended, the DSA must send the CMA written notification using Form 2067, Case Information, including any supporting documentation.

Form Resources

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

3440 Termination

Revision 11-7; Effective November 1, 2017

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

3441 Termination With Advanced Notice

Revision 11-7; 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 the DFPS, unless it is a foster family home or a foster group home;
      • a facility licensed or subject to being licensed by the DSHS;
      • a facility operated by HHSC; or
      • a residential facility operated by the Texas Youth Commission, a jail or prison;
  • 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 on the basis of a reasonable expectation that the individual's medical and nursing needs cannot be met adequately in the individual's residence; or
  • the individual refuses to comply with one or more of the mandatory participation requirements 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, HHSC may extend this time frame in 30 calendar-day increments.);
    • not participating with the SPT to:
      • develop the IPP-A using the person-centered planning process;
      • develop an enrollment CFC/CLASS IPC; or
      • renew and revise the IPC and IPPs;
    • not reviewing, agreeing to, signing and dating an IPC and IPPs;
    • not using natural supports and other non-CLASS services and supports for which the individual may be eligible before using CLASS and CFC services;
    • not cooperating with the CMA and DSA in the delivery of CLASS and CFC services listed on the individual's IPC, including:
      • not cooperating with the CMA and DSA in scheduling meetings;
      • not attending scheduled meetings with the case manager or service provider;
      • not being available to receive the CLASS and CFC services;
      • not 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;
      • not admitting CMA and DSA representatives to the individual's own home or family home for a scheduled meeting or to receive CLASS and CFC services;
    • not cooperating with the DSA's service providers to ensure progress toward achieving the goals and objectives described in the IPP for each CLASS service listed on the IPC;
    • not paying a required copayment in a timely manner as required by HHSC;
    • not completing the procedures for redetermining eligibility for Medicaid as described in the Medicaid for the Elderly and People with Disabilities Handbook;
    • engaging or permitting a person present in the individual's own or family home to engage in criminal behavior in the presence of the case manager or service provider;
    • acting or 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 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 service provider in immediate jeopardy;
    • initiating or participating in fraudulent health care practices; or
    • engaging or 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.

Within two business days after the DSA learns of one of the situations described above, the DSA must send the CMA a written notification per Form 2067, Case Information, including supporting documentation. The DSA is responsible for making reasonable attempts to accommodate a face-to-face meeting with the SPT as scheduled by the CMA.

If termination of services is requested based on a determination by the DSA on the basis of a reasonable expectation that the individual's medical and nursing needs cannot be met adequately in the individual's residence, the DSA must provide specific reason(s) to the CMA regarding why the DSA determined 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 DSA must assist the CMA to develop a transfer IPC as described in Section 3340 of the CLASS Provider Manual.

HHSC notifies the individual's CMA, in writing, of whether it authorizes the proposed termination of CLASS program and CFC services. The DSA is notified by the CMA regarding the termination.

If CLASS program and CFC 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 and CFC services and includes in the notice the individual's right to request a fair hearing. HHSC sends a copy of the written notice to the individual's DSA, CMA and, if selected, FMSA.

HHSC notifies the individual's CMA, in writing, of whether it authorizes the proposed termination of CLASS program and CFC services. The DSA is notified by the CMA regarding the termination.

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

3442 Termination Without Advanced Notice

Revision 17-1; Effective November 17, 2017

HHSC terminates an individual's CLASS program and CFC 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 continue to receive CLASS program and CFC 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. For more information, see Section 3510, Immediate Jeopardy.

Within two business days after the DSA becomes aware of a situation such as described above, the DSA must send the CMA a written notification per Form 2067, Case Information, including supporting documentation.

HHSC notifies the individual's CMA, in writing, of whether it authorizes the termination of CLASS and CFC services. The DSA is notified by the CMA regarding the termination.

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

If a CMA or DSA becomes aware of an existing situation that places the health and safety of the individual's case manager or 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;
  • notify the CMA or DSA, as appropriate, and HHSC by telephone of the situation no later than the next business day; and
  • attempt to resolve the situation.

HHSC notifies the individual's CMA, in writing, of whether it authorizes the proposed termination of CLASS and CFC services. The DSA is notified by the CMA regarding the termination.

Form Resources

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