(a) Eligibility for residential care is based on the following criteria:
  (1) the applicant must be income eligible or Medicaid eligible (not in an institution);
  (2) the applicant must meet the 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) the applicant's needs may not exceed the facility's capability under its licensed authority; and
  (4) the applicant must have financial resources at or below the level established by the department.
(b) The client must contribute to the total cost of the care that he receives, including payment for room and board. The room and board amount is calculated from the client's gross income. The client is responsible for paying this amount directly to the provider agency. The client may be required to pay a copayment based on the amount of income remaining after all allowances are deducted.
  (1) The client keeps a monthly allowance for his personal and medical expenses. The Medicaid client keeps $123; a qualified Medicare beneficiary (non-Medicaid) keeps $182; and the non-Medicaid, non-QMB client keeps $211 and the part B Medicare premium fee.
  (2) In addition to the monthly allowance, a client with earned income keeps all of the earned income up to a maximum of $65 per month.
  (3) In no case may the client's contribution, when added to the department's payment, exceed the rate established for residential care.
(c) The client is eligible for 14 days of personal leave from the residential care facility each calendar year. If the client does not pay the bedhold charge for days of personal leave that exceed the limits, he may lose his space in the facility.
(d) To reserve his space in the facility during hospital, nursing home, or institutional stays, the client must pay his copayment or the facility's bedhold charge, whichever is lower. If the copayment amount is less than the bedhold charge, the department pays the difference. Nursing home and institutional stays are limited to 30 days. There is no limit to the length of hospital stays.

Source Note: The provisions of this §271.85 adopted to be effective December 5, 1986, 11 TexReg 4755; amended to be effective April 15, 1990, 15 TexReg 1070; amended to be effective January 1, 1992, 16 TexReg 6860; amended to be effective March 15, 1999, 24 TexReg 1193; amended to be effective September 1, 2003, 28 TexReg 6951; 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