5200, CLASS Cost Limits

Revision 17-1; Effective November 1, 2017

This section describes utilization review (UR)  cost limits and service limits employed during review of a proposed IPC. HHSC may, at its discretion, select any proposed IPC for UR, regardless of total cost of services. HHSC selects a proposed IPC for UR at its discretion any time the agency receives a proposed IPC and will verify the IPC does not exceed the CLASS cost ceiling of $114,736.07. CLASS UR also verifies that CLASS services do not exceed a maximum combined cost of $10,000 for adaptive aids and dental treatment and $10,000 for minor home modifications. The IPC must not include more than 30 days of in-home respite and out-of-home respite combined. CFC services, which are subject to utilization review, are not included when verifying the cost ceiling is not surpassed.

As necessary, HHSC will coordinate with the individual's CMA to request additional justification information for proposed services and amounts of services included in an individual's proposed IPC as part of the UR process. The CMA is responsible to respond to HHSC’s UR requests in accordance with the CLASS rule in Title 40 of the Texas Administrative Code (TAC), §45.214. The CMA must submit any requested additional documentation supporting the proposed IPC to HHSC within 10 calendar days after HHSC’s request.