(a) A program provider may request a level one enhanced staffing rate for off-site individualized skills and socialization described in §262.925(b) of this subchapter (relating to Program Provider Reimbursement for On-Site, Off-Site, and In-Home Individualized Skills and Socialization) for an individual with a LON 1 or LON 5 who receives off-site individualized skills and socialization from the program provider.
(b) A program provider may request a level two enhanced staffing rate for off-site individualized skills and socialization described in §262.925(b) of this subchapter for an individual with a LON 1, LON 5, LON 8, or LON 6 who receives off-site individualized skills and socialization from the program provider.
(c) A service coordinator must request a level one enhanced staffing rate for an individual with a LON 1 or LON 5 or request a level two enhanced staffing rate for an individual with a LON 1, LON 5, LON 8, or LON 6 for off-site individualized skills and socialization described in §262.925(b) of this subchapter for an individual who receives off-site individualized skills and socialization through the CDS option if the CDS employer asks the service coordinator to request the enhanced staffing rate.
(d) A program provider or service coordinator makes the request described in subsections (a) - (c) of this section by submitting the following documentation to HHSC:
  (1) a completed HHSC Enhanced Staffing Rate Request Form;
  (2) the most recent ICAP scoring booklet;
  (3) the most recent ID/RC Assessment;
  (4) the most recent PDP;
  (5) the most recent implementation plan for individualized skills and socialization; and
  (6) other documentation that supports the individual's request for an enhanced staffing rate, which may include:
    (A) the behavior support plan;
    (B) a physician's order;
    (C) an assessment completed by a service provider of a professional therapy;
    (D) the nursing assessment; and
    (E) the CFC PAS/HAB assessment.
(e) HHSC approves a request made in accordance with subsections (a) - (d) of this section if the documentation submitted to HHSC demonstrates that to participate in off-site individualized skills and socialization, the individual requires more service provider support than the individual typically receives. The requirement for additional support may be because of the individual's mobility, medical, or behavioral needs.
(f) HHSC may review an approved enhanced staffing rate at any time to determine if it is appropriate. If HHSC reviews an enhanced staffing rate, a program provider or service coordinator must submit documentation supporting the enhanced staffing rate to HHSC in accordance with HHSC's request.
(g) HHSC notifies a program provider or service coordinator that an enhanced staffing rate is approved or denied through the HHSC data system.
(h) A service coordinator must notify the CDS employer and FMSA of HHSC's approval or denial described in subsection (g) of this section.
(i) A program provider may request an administrative hearing in accordance with 1 TAC §357.484 (relating to Request for a Hearing) if HHSC:
  (1) denies a request made in accordance with subsection (a) or (b) of this section; or
  (2) denies an enhanced staffing rate based on a review described in subsection (f) of this section.

Source Note: The provisions of this §262.927 adopted to be effective January 1, 2023, 47 TexReg 8688