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.