Texas Register, Volume 22, Number 80, Pages 12189-12342, December 12, 1997 Page: 12,246
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(b) An applicant who meets the criteria described in sub-
section (a) of this section much have an IPC for MRLA program
services developed by an appropriately constituted interdisciplinary
team. The team must include a case manager from the mental re-
tardation authority (MRA) and the individual and/or the individual's
legally authorized representative.
(1) The individual's initial IPC is developed by the MRA
and approved by TDMHMR. Revisions and updates to the initial IPC
are made by the MRA and approved by TDMHMR.
(2) The IPC must be updated by the MRA at least
annually. Revisions and updates to subsequent plans of care made
by the MRA are reviewed and approved by TDMHMR. Payments by
TDMHMR to a provider will not be disrupted in the event the MRA
erroneously fails to submit an enrolled individual's IPC for renewal
and the provider continues to provide services in accordance with the
most recent IPC as approved by TDMHMR.
(3) An individual will be determined eligible for MRLA
program services if the estimated annual cost of services in the
individual's IPC does not exceed 100% of the estimated annualized
per capita cost for ICF/MR services. If an individual's IPC cost
exceeds 100% of the estimated annualized per capita cost for ICF/
MR services, the individual will be eligible for MRLA program
services if TDMHMR approves reimbursement and the IPC cost
does not exceed 125% of the annual ICF/MR reimbursement rate
paid to a small ICF/MR, as defined in 1 TAC 355.456 (relating
to Rate Setting Methodology), for the individual's level of need
as it would be assigned under 406.204(b) of this title (relating
to Level-of-Care Determination and Level-of-Need Assignment) or
125% of the estimated annualized per capita cost for ICF/MR
services, whichever is greater. Services included in the IPC must
be based on the individual's condition and environment, be necessary
to prevent institutionalization, and supplement rather than replace the
individual's natural supports in the community.
(c) Any individual whose MRLA program services have been
suspended or reduced with the approval of TDMHMR may request an
informal review by TDMHMR. A request for an informal review must
be submitted to the TDMHMR Office of Medicaid Administration and
received within 90 days from the date of the notice of suspension or
reduction of MRLA program services.
(d) Any individual whose request for eligibility for the
MRLA program is denied or is not acted upon with reasonable
promptness, or whose MRLA program services have been terminated,
suspended or reduced by TDMHMR, is entitled to a fair hearing
conducted by the Texas Department of Human Services (TDHS) in
accordance with 40 TAC 79.1101 et seq., except that a request for a
fair hearing must be submitted to the TDMHMR Office of Medicaid
Administration and received within 90 days from the date of the
notice of denial of eligibility for the MRLA program or notice of
termination, suspension, or reduction of MRLA program services.
(e) Enrollment in the MRLA program is limited to the
number of individuals approved by HCFA and allocated to each MRA.
{fl Persons who enter the MRLA program from the HCS
program will retain the HCS or HCS-O IPC in effect at the time
of transfer to the MRLA program. The effective date of the IPC
established for the HCS or HCS-O program will not be changed.
Any modifications or billing against the MRLA IPC will take into
consideration previous billing against the HCS or HCS-O IPCs. At
the time of transition to the MRLA program, the only portion of the
IPC that will be modified for HCS consumers will be the deletion of
case management from the IPC.409.507. Payment Category Assignment and Provider Claims Pay-
ment.
(a) Payment to providers for supported home living, counsel-
ing and therapies, respite, and nursing is based upon the unit reim-
bursement rate for the specific service component.
(b} TDMHMR will reimburse providers the actual cost of
minor home modifications, adaptive aids, and dental services in
accordance with the waiver request and limits noted in 409.503,
as approved by HCFA, the MRLA provider contract, the individual's
IPC, and provider manual.
(c Reimbursement for MRLA services foster/companion/
companion care, residential support, and day habilitation is based
upon the program participant's payment category assignment and the
reimbursement rate for the specific service component provided.
(1) The payment category for a program participant
is based upon a level-of-need (LON) assignment approved by
TDMHMR or its designee as part of the level-of-care determination
according to 25 TAC 409.103. LON assignments are derived
from the service level score obtained from the administration of the
Inventory for Client and Agency Planning (ICAP) to the program
applicant/participant and from selected items on the level-of-care
assessment form.
(A) A MRLA program applicant or participant is
assigned one of the following five levels of need:
(i) An intermittent LON (LON 1) is assigned if the
ICAP service level score equals 7, 8, or 9;
ii) A limited LON (LON 5) is assigned if the ICAP
service level score equals 4, 5, or 6;
iii) An extensive LON (LON 8) is assigned if the
ICAP service level score equals 2 or 3;
iv) A pervasive LON (LON 6) is assigned if the
ICAP service level score equals 1; or
(v) A "pervasive plus" LON (LON 9) is assigned
when the level-of-care assessment form documents an intervention
code of 2 on at least one of Items 70-73.
IB) The LON assignment may be modified to take
into account extraordinary service needs that result from unusual
behavioral challenges. The LON for these individuals combines
ICAP service level scores and needs identified on selected items on
the level-of-care assessment form. A LON that does not directly
correspond to the ICAP service level score will be subject to
utilization review by TDMHMR.
_ Individuals who have very challenging behaviors
that require a behavior intervention program that includes constant
preventive actions by additional provider staff will be assigned the
next higher LON from the original level. Additional staff may assist
in the supervision of other individuals. Individuals originally assigned
a pervasive LON will retain that assignment. Very challenging
behaviors have the following characteristics:
(I) The behavior presents a danger to the indi-
vidual or to others;
(II) The behavior warrants individualized objec-
tives which include written intervention procedures;
(III) The frequency of the behavior is reduced
only with constant staffing and a highly structured environment;22 TexReg 12246 December 12, 1997 Texas Register
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Texas. Secretary of State. Texas Register, Volume 22, Number 80, Pages 12189-12342, December 12, 1997, periodical, December 12, 1997; Austin, Texas. (https://texashistory.unt.edu/ark:/67531/metapth176721/m1/60/?rotate=270: accessed July 18, 2024), University of North Texas Libraries, The Portal to Texas History, https://texashistory.unt.edu; crediting UNT Libraries Government Documents Department.