(a) To be eligible for primary home care or community attendant (CA) services, the applicant/client must:
  (1) be eligible for Medicaid in a community setting or be eligible under the provisions of the Social Security Act, §1929(b)(2)(B);
  (2) meet the minimum functional need criteria as set by the department. The department uses a standardized assessment instrument to measure the client's ability to perform activities of daily living. This yields a score, which is a measure of the client's level of functional need. The department sets the minimum required score for a client to be eligible, which the department may periodically adjust commensurate with available funding. The department will seek stakeholder input before making any change in the minimum required score for functional eligibility;
  (3) have a medical need for assistance with personal care.
    (A) The client's medical condition must be the cause of the client's functional impairment in performing personal care tasks.
    (B) Persons diagnosed with mental illness, mental retardation, or both, are not considered to have established medical need based solely on such diagnosis. The diagnoses do not disqualify a client for eligibility as long as the client's functional impairment is related to a coexisting medical condition;
  (4) have a signed and dated practitioner's statement that includes a statement that the client has a current medical need for assistance with personal care tasks and other activities of daily living; and
  (5) require at least six hours of service per week. An applicant/client requiring fewer than six hours of service per week may be eligible if the applicant/client:
    (A) requires primary home care or community attendant services to provide respite care to the caregiver;
    (B) lives in the same household as another individual receiving primary home care, community attendant services, family care, or community based alternatives personal assistance services;
    (C) receives one or more of the following services (through the department or other resources):
      (i) congregate or home-delivered meals;
      (ii) assistance with activities of daily living from a home health aide;
      (iii) day activity and health services; or
      (iv) special services to persons with disabilities in adult day care;
    (D) receives aid-and-attendance benefits from the Veterans Administration;
    (E) receives services through the department's In-home and Family Support Program;
    (F) receives services through the Medically Dependent Children Program (MDCP); or
    (G) is determined, based upon the functional assessment, to be at high risk of institutionalization without primary home care or community attendant care services.
(b) To receive services, the applicant/client must reside in a place other than:
  (1) a hospital;
  (2) a skilled nursing facility;
  (3) an intermediate care facility;
  (4) an assisted living facility;
  (5) a foster care setting;
  (6) a jail or prison;
  (7) a state school;
  (8) a state hospital; or
  (9) any other setting where sources outside the primary home care program are available to provide personal care.
(c) A client with priority status may receive no more than 42 hours of service per week. A client without priority status may receive no more than 50 hours of service per week.
(d) The community care case manager establishes a priority status for each client based on the functional assessment. An individual is considered to have priority status if the following criteria are met:
  (1) The individual is completely unable to perform one or more of the following activities without hands-on assistance from another person:
    (A) transferring himself into or out of bed or a chair or on off a toilet;
    (B) feeding himself;
    (C) getting to or using the toilet;
    (D) preparing a meal; or
    (E) taking self-administered prescribed medications.
  (2) During a normally scheduled service shift, no one is readily available who is capable and who is willing to provide the needed assistance other than the attendant.
  (3) The community care case manager determines that there is a high likelihood the individual's health, safety, or well-being would be jeopardized if services were not provided on a single given shift.

Source Note: The provisions of this §271.81 adopted to be effective November 1, 1982, 7 TexReg 3504; amended to be effective August 1, 1984, 9 TexReg 3876; amended to be effective January 1, 1986, 10 TexReg 4696; amended to be effective July 1, 1986, 11 TexReg 2827; amended to be effective October 21, 1988, 13 TexReg 4529; amended to be effective September 1, 1990, 15 TexReg 4579; amended to be effective September 3, 1991, 16 TexReg 4493; amended to be effective May 15, 1992, 17 TexReg 3162; amended to be effective July 1, 1992, 17 TexReg 3999; amended to be effective August 5, 1992, 17 TexReg 5121; amended to beeffectiveOctober 1, 1992, 17 TexReg 6374; amended to be effective November 15, 1992, 17 TexReg 7464; amended to be effective September 1, 1993, 18 TexReg 4754; amended to be effective October 1, 1994, 19 TexReg 6234; amended to be effective July 1, 1996, 21 TexReg 5326; amended to be effective February 15, 1997, 22 TexReg 905; amended to be effective August 31, 2004, 29 TexReg 8376; transferred effective September 15, 2023, as published in the August 18, 2023, issue of the Texas Register, 48 TexReg 4523