(a) After HHSC notifies a CMA, as described in §259.55(c) of this division (relating to Written Offer of CLASS Program Services), that an individual selected the CMA, the CMA must assign a case manager to perform the following functions as soon as possible, but no later than 14 calendar days after HHSC's notification:
  (1) verify that the individual resides in the catchment area for which the individual's selected CMA and DSA have a contract;
  (2) conduct an initial in-person visit in the individual's residence with the individual and LAR or actively involved person at a time convenient to the individual and LAR to:
    (A) provide an oral and written explanation of the following to the individual and LAR or actively involved person:
      (i) CLASS Program services, including TAS if the individual is receiving institutional services;
      (ii) CFC services;
      (iii) the mandatory participation requirements of an individual described in §259.103 of this chapter (relating to Mandatory Participation Requirements of an Individual);
      (iv) the CDS option described in §259.71 of this division (relating to CDS Option);
      (v) the right to request a fair hearing in accordance with §259.101 of this chapter (relating to Individual's Right to a Fair Hearing);
      (vi) that the individual, LAR, or actively involved person may report an allegation of abuse, neglect, or exploitation to DFPS by calling the toll-free telephone number at 1-800-252-5400;
      (vii) the process by which the individual, LAR, or actively involved person may file a complaint regarding case management as required by 40 TAC §49.309 (relating to Complaint Process);
      (viii) that the HHSC Office of the Ombudsman toll-free telephone number at 1-877-787-8999 may be used to file a complaint regarding the CMA;
      (ix) voter registration, if the individual is 18 years of age or older;
      (x) that, while the individual is staying at a location outside the catchment area in which the individual resides but within the state of Texas for a period of no more than 60 consecutive days, the individual and LAR or actively involved person may request that the DSA provide:
        (I) transportation as a habilitation activity, as described in §259.5(56)(B)(i)(IX) of this subchapter (relating to Definitions);
        (II) out-of-home respite in a camp described in §259.361(b)(2)(D) of this chapter (relating to Respite and Dental Treatment);
        (III) adaptive aids;
        (IV) nursing; and
        (V) CFC PAS/HAB;
      (xi) the use of electronic visit verification, as required by 1 TAC Chapter 354, Subchapter O; and
      (xii) how to contact the individual's case manager; and
    (B) use the HHSC Understanding Program Eligibility - CLASS/DBMD form to provide an oral and written explanation to the individual or LAR, and obtain the individual's or LAR's signature and date on the form, to acknowledge understanding of:
      (i) the eligibility requirements for:
        (I) CLASS Program services, as described in §259.51(a) of this subchapter (relating to Eligibility Criteria for CLASS Program Services and CFC Services);
        (II) CFC services for individuals who do not receive MAO Medicaid, as described in §259.51(b) of this subchapter; and
        (III) CFC services for individuals who receive MAO Medicaid, as described in §259.51(c) of this subchapter;
      (ii) the reasons CLASS Program services and CFC services may be suspended, as described in §259.157 of this chapter (relating to Suspension of CLASS Program Services or CFC Services); and
      (iii) that CLASS Program services and CFC services may be terminated as described in §§259.161, 259.163, 259.165, and 259.167 of this chapter (relating to Termination of CLASS Program Services and CFC Services With Advance Notice for Reasons Other Than Non-compliance with Mandatory Participation Requirements; Termination of CLASS Program Services and CFC Services With Advance Notice Because of Non-compliance With Mandatory Participation Requirements; Termination of CLASS Program Services and CFC Services Without Advance Notice for Reasons Other Than Behavior Causing Immediate Jeopardy; and Termination of CLASS Program Services and CFC Services Without Advance Notice Because of Behavior Causing Immediate Jeopardy); and
    (C) educate the individual, LAR, and actively involved person about protecting the individual from abuse, neglect, and exploitation; and
  (3) give the individual or LAR the HHSC Waiver Program Verification of Freedom of Choice form to document the individual's or LAR's choice regarding the CLASS Program or the ICF/IID Program.
(b) A CMA must:
  (1) as soon as possible, but no later than two business days after the case manager's initial in-person visit required by subsection (a)(2) of this section:
    (A) collect the information necessary for the CMA and DSA to process the individual's request for enrollment into the CLASS Program in accordance with the Community Living Assistance and Support Services Provider Manual; and
    (B) provide the individual's selected DSA with the information collected in accordance with subparagraph (A) of this paragraph;
  (2) assist the individual or LAR in completing and submitting an application for Medicaid financial eligibility, as required by §259.103(1) of this chapter; and
  (3) ensure that the case manager documents in the individual's record the progress toward completing a Medicaid application and enrolling into the CLASS Program.
(c) If an individual or LAR does not submit a Medicaid application to HHSC within 30 calendar days after the case manager's initial in-person visit, as required by §259.103(1) of this chapter, but is making good faith efforts to complete the application, the CMA:
  (1) may extend, in 30-calendar day increments, the time frame in which the application must be submitted to HHSC, except as provided in paragraph (2) of this subsection;
  (2) must not grant an extension that results in a time period of more than 365 calendar days from the date of the case manager's initial in-person visit; and
  (3) must ensure that the case manager documents each extension in the individual's record.
(d) If an individual or LAR does not submit a Medicaid application to HHSC within 30 calendar days after the case manager's initial in-person visit, as required by §259.103(1) of this chapter, and is not making good faith efforts to complete the application, a CMA must request, in writing, that HHSC withdraw the offer of enrollment made to the individual in accordance with §259.55(d)(2) of this division.
(e) If a DSA serving the catchment area in which an individual resides is not willing to provide CLASS Program services or CFC services to the individual because the DSA has determined that it cannot ensure the individual's health and safety, the CMA must provide to HHSC, in writing, the specific reasons the DSA has determined that it cannot ensure the individual's health and safety.
(f) During the initial in-person visit described in subsection (a)(1) of the section, the case manager must determine whether an individual meets the following criteria:
  (1) the individual is being discharged from a nursing facility or an ICF/IID;
  (2) the individual has not previously received TAS;
  (3) the individual's proposed enrollment IPC will not include SFS; and
  (4) the individual anticipates needing TAS.
(g) If a case manager determines that an individual meets the criteria described in subsection (f) of this section, the case manager must:
  (1) provide the individual or LAR with a list of TAS providers in the catchment area in which the individual will reside;
  (2) complete, with the individual or LAR, the HHSC Transition Assistance Services (TAS) Assessment and Authorization form found on the HHSC website in accordance with the form's instructions, which includes:
    (A) identifying the items and services described in §272.5(e) of this title (relating to Service Description) that the individual needs;
    (B) estimating the monetary amount for the items and services identified on the form, which must be within the service limit described in §259.73(a)(4) of this division (relating to Service Limits); and
Cont'd...
(C) documenting the individual's or LAR's choice of TAS provider;
  (3) submit the completed form to HHSC for authorization;
  (4) if HHSC authorizes the form, send the form to the TAS provider chosen by the individual or LAR; and
  (5) include TAS and the monetary amount authorized by HHSC on the individual's proposed enrollment IPC.
(h) A DSA must ensure that the following functions are performed during an in-person visit in the individual's residence at a time convenient to the individual and LAR as soon as possible, but no later than 14 calendar days after the CMA provides information to the DSA as required by subsection (b)(1)(B) of this section:
  (1) a DSA staff person must:
    (A) inform the individual and LAR or actively involved person, orally and in writing:
      (i) that the individual, LAR, or actively involved person may report an allegation of abuse, neglect, or exploitation to DFPS by calling the toll-free telephone number at 1-800-252-5400;
      (ii) the process by which the individual, LAR, or actively involved person may file a complaint regarding CLASS Program services or CFC services provided by the DSA as required by 40 TAC §49.309; and
      (iii) that the HHSC Complaint and Incident Intake toll-free telephone number at 1-800-458-9858 may be used to file a complaint regarding the DSA; and
    (B) educate the individual and LAR or actively involved person about protecting the individual from abuse, neglect, and exploitation;
  (2) an appropriate professional must complete an adaptive behavior screening assessment in accordance with the assessment instructions; and
  (3) an RN, in accordance with the Community Living Assistance and Support Services Provider Manual, must complete:
    (A) a nursing assessment, using the HHSC CLASS/DBMD Nursing Assessment form;
    (B) the HHSC Related Conditions Eligibility Screening Instrument form; and
    (C) the ID/RC Assessment.
(i) A DSA must:
  (1) ensure that the primary diagnosis of the individual documented on the ID/RC Assessment is approved by a physician;
  (2) submit the following documentation to HHSC for HHSC's determination of whether the individual meets the LOC VIII criteria required by §259.51(a)(2) of this subchapter:
    (A) the completed adaptive behavior screening assessment;
    (B) the completed HHSC Related Conditions Eligibility Screening Instrument form; and
    (C) the completed ID/RC Assessment; and
  (3) send the completed HHSC CLASS/DBMD Nursing Assessment form described in subsection (h)(3)(A) of this section to the CMA.
(j) In accordance with §259.63(a)(1) of this division (relating to Determination by HHSC of Whether an Individual Meets LOC VIII Criteria), HHSC reviews the documentation described in subsection (i)(2) of this section.
(k) If a DSA receives written notice from HHSC in accordance with §259.63(c)(1) of this division that an individual meets the LOC VIII criteria, the DSA must notify the individual's CMA of HHSC's decision as soon as possible, but no later than one business day after receiving the notice from HHSC.
(l) If HHSC determines that an individual does not meet the LOC VIII criteria, HHSC sends written notice of the denial of the individual's request for enrollment into the CLASS Program:
  (1) to the individual or LAR in accordance with §259.153(b) of this chapter (relating to Denial of a Request for Enrollment into the CLASS Program); and
  (2) to the individual's DSA and CMA in accordance with §259.63(d) of this division.
(m) If a CMA receives notice from a DSA, as described in subsection (k) of this section, that HHSC determined that an individual meets the LOC VIII criteria, the case manager must:
  (1) ensure that the service planning team meets in person or by videoconferencing to develop:
    (A) a proposed enrollment IPC, a PAS/HAB plan, IPPs, and an HHSC IPP Addendum form for the individual in accordance with §259.65 of this division (relating to Development of an Enrollment IPC); and
    (B) an individual transportation plan, if transportation as a habilitation activity or as an adaptive aid is included on the proposed enrollment IPC; and
  (2) submit the documents described in paragraph (1) of this subsection to HHSC for review in accordance with §259.65 of this division.
(n) HHSC reviews a proposed enrollment IPC in accordance with §259.69 of this division (relating to HHSC's Review of a Proposed Enrollment IPC) to determine if:
  (1) the proposed enrollment IPC has an IPC cost at or below the amount in §259.51(a)(4) of this subchapter; and
  (2) the CLASS Program services and CFC services specified in the proposed enrollment IPC meet the requirements described in §259.65(a)(1)(E)(iii) or (iv) and §259.65(b) of this division.
(o) A CMA and DSA must not provide a CLASS Program service or CFC service to an individual before HHSC notifies the CMA, in accordance with §259.69(c)(1) of this division, that the individual's request for enrollment into the CLASS Program has been approved. If a CMA or DSA provides CLASS Program services or CFC services to an individual before the effective date of the individual's enrollment IPC authorized by HHSC, HHSC does not reimburse the CMA or DSA for those services.
(p) If HHSC notifies a CMA in accordance with §259.69(c)(1) of this division that an individual's request for enrollment is approved:
  (1) the CMA must ensure the case manager complies with §259.69(c)(2) of this division; and
  (2) the CMA and DSA must comply with §259.69(g) of this division.
(q) If HHSC notifies a CMA in accordance with §259.69(e) of this division that an individual's request for enrollment into the CLASS Program is approved, but action is being taken by HHSC to deny a CLASS Program service or CFC service and modify the proposed enrollment IPC:
  (1) the CMA must comply with §259.69(f) of this division; and
  (2) the CMA and DSA must comply with §259.69(g) of this division.

Source Note: The provisions of this §259.61 adopted to be effective January 30, 2023, 48 TexReg 362