(a) Except as provided in subsection (b) of this section, HHSC pays for on-site, off-site, and in-home individualized skills and socialization provided to an individual in accordance with an individual's LON and the reimbursement rates for on-site, off-site, and in-home individualized skills and socialization.
(b) If approved in accordance with §263.2027 of this subchapter (relating to Enhanced Staffing Rate) HHSC pays:
  (1) a level one enhanced staffing rate for off-site individualized skills and socialization for an individual with a LON 1 or LON 5; and
  (2) a level two enhanced staffing rate for off-site individualized skills and socialization for an individual with an LON 1, LON 5, LON 8, or LON 6.
(c) If an individual's HCS Program services and CFC services are suspended or terminated, a program provider must not submit a claim for on-site, off-site, or in-home individualized skills and socialization provided during the period of the individual's suspension or after the termination, except that the program provider may submit a claim for the first day of the individual's suspension or termination.
(d) HHSC does not pay a program provider for on-site, off-site, or in-home individualized skills and socialization, or recoups any payments made to the program provider for on-site, off-site, or in-home individualized skills and socialization, if:
  (1) the individual receiving on-site, off-site, or in-home individualized skills and socialization was, at the time on-site, off-site, or in-home individualized skills and socialization was provided, ineligible for the HCS Program;
  (2) on-site, off-site, or in-home individualized skills and socialization is provided to an individual during a period of time for which there is not a signed, dated, and authorized IPC for the individual;
  (3) on-site, off-site, or in-home individualized skills and socialization is provided during a period of time for which there is not a signed and dated ID/RC Assessment for the individual;
  (4) on-site, off-site, or in-home individualized skills and socialization is provided during a period of time for which the individual did not have an LOC determination;
  (5) on-site, off-site, or in-home individualized skills and socialization is not provided in accordance with a signed, dated, and authorized IPC that includes on-site, off-site, or in-home individualized skills and socialization;
  (6) on-site, off-site, or in-home individualized skills and socialization is not provided in accordance with the individual's PDP or implementation plan;
  (7) on-site, off-site, or in-home individualized skills and socialization is provided before the individual's enrollment date into the HCS Program;
  (8) on-site, off-site, or in-home individualized skills and socialization is not provided in accordance with this subchapter; (9) on-site or off-site individualized skills and socialization is not provided in accordance with Chapter 559, Subchapter H of this title (relating to Individualized Skills and Socialization Provider Requirements);
  (10) on-site, off-site, or in-home individualized skills and socialization is not provided in accordance with the HCS Program Billing Requirements;
  (11) on-site, off-site, or in-home individualized skills and socialization is not documented in accordance with the HCS Program Billing Requirements;
  (12) the program provider did not comply with 40 TAC §49.305 (relating to Records);
  (13) the claim for on-site, off-site, or in-home individualized skills and socialization did not meet the requirements in 40 TAC §49.311 (relating to Claims Payment) or the HCS Program Billing Requirements;
  (14) HHSC determines that on-site, off-site, or in-home individualized skills and socialization would have been paid for by a source other than the HCS Program if the program provider had submitted to the other source a proper, complete, and timely request for payment for on-site, off-site, or in-home individualized skills and socialization;
  (15) on-site or off-site individualized skills and socialization is provided by a service provider who did not meet the qualifications to provide on-site or off-site individualized skills and socialization in accordance with §559.227(a) of this title (relating to Program Requirements) and the HCS Program Billing Requirements;
  (16) in-home individualized skills and socialization is provided by a service provider who did not meet the qualifications to provide in-home individualized skills and socialization as described in §263.2023 of this subchapter (relating to Service Provider Qualifications and Training for In-Home Individualized Skills and Socialization) and the HCS Program Billing Requirements;
  (17) on-site, off-site, or in-home individualized skills and socialization was paid at an incorrect LON because the information entered in the HHSC data system from a completed ID/RC Assessment is not identical to the information on the completed ID/RC Assessment;
  (18) on-site, off-site, or in-home individualized skills and socialization was not provided;
  (19) on-site or off-site individualized skills and socialization is provided during a period of time that the individual produced marketable goods and was paid below minimum wage for producing the goods in accordance with Section 14(c) of the Fair Labor Standards Act;
  (20) in-home individualized skills and socialization is not provided in the residence of the individual as required by §263.2013(a) of this subchapter (relating to Provision of In-Home Individualized Skills and Socialization); or
  (21) in-home individualized skills and socialization is provided to an individual without the documentation required by §263.2013(c) of this subchapter.
(e) HHSC does not pay a program provider for day habilitation, or recoups any payments made to the program provider for day habilitation, if day habilitation is provided on or after March 1, 2023, even if an individual's IPC includes day habilitation on or after March 1, 2023.
(f) HHSC conducts provider fiscal compliance reviews, also known as billing and payment reviews, in accordance with rules governing the HCS Program and the HCS Program Billing Requirements to determine whether a program provider is in compliance with this subchapter.

Source Note: The provisions of this §263.2025 adopted to be effective January 1, 2023, 47 TexReg 8698