(a) A program provider may request a level one enhanced staffing rate for off-site individualized skills and socialization described in §263.2025(b) of this subchapter (relating to Program Provider Reimbursement for Individualized Skills and Socialization) for an individual with a LON 1 or LON 5 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.
(b) A program provider may request a level two enhanced staffing rate for off-site individualized skills and socialization described in §263.2025(b) of this subchapter for an individual with a LON 1, LON 5, LON 8, or LON 6 by submitting the documentation described in subsection (a) of this section.
(c) HHSC approves a request made in accordance with subsection (a) or (b) 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 would receive with the individual's assigned LON. The requirement for additional support may be because of the individual's mobility, medical, or behavioral needs.
(d) 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 must submit documentation supporting the enhanced staffing rate to HHSC in accordance with HHSC's request.
(e) HHSC notifies a program provider that an enhanced staffing rate is approved or denied through the HHSC data system.
(f) 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 (d) of this section.

Source Note: The provisions of this §263.2027 adopted to be effective January 1, 2023, 47 TexReg 8698