§9.555: Definitions of Txhml Program Service Components

(a) The community support service component provides services and supports in an individual's home and at other community locations that are necessary to achieve outcomes identified in an individual's PDP.

(1) The community support service component provides habilitative or support activities that:

(A) provide or foster improvement of or facilitate an individual's ability to perform functional living skills and other activities of daily living;

(B) assist an individual to develop competencies in maintaining the individual's home life;

(C) foster improvement of or facilitate an individual's ability and opportunity to:

(i) participate in typical community activities including activities that lead to successful employment;

(ii) access and use of services and resources available to all citizens in the individual's community;

(iii) interact with members of the community;

(iv) access and use available non-TxHmL Program services or supports for which the individual may be eligible; and

(v) establish or maintain relationships with people, who are not paid service providers, that expand or sustain the individual's natural support network.

(2) The community support service component provides assistance with medications and the performance of tasks delegated by a registered nurse in accordance with state law.

(3) The community support service component does not include payment for room or board.

(4) The community support service component may not be provided at the same time that the respite, day habilitation, or supported employment service component is provided.

(5) The community support service component is reimbursed on an hourly basis.

(b) The day habilitation service component assists an individual to acquire, retain, or improve self-help, socialization, and adaptive skills necessary to live successfully in the community and participate in home and community life and does not include services that are funded under §110 of the Rehabilitation Act of 1973 or §602(16) and (17) of the Individuals with Disabilities Education Act.

(1) The day habilitation service component provides:

(A) individualized activities consistent with achieving the outcomes identified in the individual's PDP;

(B) activities necessary to reinforce therapeutic outcomes targeted by other waiver service components, school, or other support providers;

(C) services in a group setting other than the individual's home for normally up to five days a week, six hours per day;

(D) personal assistance for an individual who cannot manage personal care needs during the day habilitation activity;

(E) assistance with medications and the performance of tasks delegated by a registered nurse in accordance with state law; and

(F) transportation during the day habilitation activity necessary for the individual's participation in day habilitation activities.

(2) The day habilitation component may not be provided at the same time supported employment is provided to an individual who has obtained employment.

(3) The day habilitation component is reimbursed on a daily or one-half day unit basis.

(c) The nursing service component provides treatment and monitoring of health care procedures as prescribed by a physician or medical practitioner or as required by standards of professional practice or state law to be performed by a licensed nurse.

(1) The nursing service component includes:

(A) administration of medication;

(B) monitoring an individual's use of medications;

(C) monitoring an individual's health data and information;

(D) assisting an individual or LAR to secure emergency medical services for the individual;

(E) making referrals for appropriate medical services;

(F) performing health care procedures as ordered or prescribed by a physician or medical practitioner or as required by standards of professional practice or law to be performed by licensed nursing personnel; and

(G) delegating and monitoring tasks assigned to other service providers by a registered nurse in accordance with state law.

(2) The nursing service component is reimbursed on an hourly unit basis.

(d) The employment assistance service component assists an individual to locate paid employment in the community.

(1) The employment assistance component assists an individual with the participation of the LAR to identify:

(A) the individual's employment preferences;

(B) the individual's job skills;

(C) the individual's requirements for the work setting and work conditions; and

(D) prospective employers that may offer employment opportunities compatible with the individual's identified preferences, skills, and requirements.

(2) The employment assistance provider facilitates the individual's employment by contacting prospective employers and negotiating the individual's employment.

(3) Employment assistance is reimbursed on an hourly unit basis.

(4) The employment assistance service component must be re-authorized by the individual's service planning team every 180 calendar days after the initiation of the service component.

(e) The supported employment service component provides ongoing individualized supports needed by an individual to sustain paid work in an integrated work setting.

(1) An individual receiving supported employment is:

(A) compensated directly by the individual's employer in accordance with the Fair Labor Standards Act; and

(B) employed in an integrated work setting by an employer that has no more than one employee or 3.0% of its employees with disabilities unless the individual's PDP indicates otherwise or the employer subsequently hires an additional employee with disabilities who is receiving services from a provider other than the individual's program provider or who is not receiving services.

(2) Supported employment may only be provided when the service has been denied or is otherwise unavailable to an individual through a program operated by a state rehabilitation agency or the public school system.

(3) Supported employment is provided away from the individual's place of residence.

(4) Supported employment does not include payment for the supervisory activities rendered as a normal part of the business setting.

(5) Supported employment does not include services provided to an individual who does not require such services to continue employment.

(6) An individual's program provider may not be the employer of an individual receiving supported employment unless a variance is approved by DADS in accordance with paragraph (7) or (8) of this subsection. DADS may approve a variance for a period of time not to exceed one year.

(7) DADS may approve a variance of the requirement in paragraph (6) of this subsection if, at the time the applicant or LAR chooses enrollment in the TxHmL Program, the applicant is receiving DADS general revenue funded supported employment from a program provider, the program provider is the applicant's employer, the applicant or LAR requests the program provider to continue providing supported employment to the applicant after enrollment, and the program provider submits a written request for the variance to DADS before the effective date of the applicant's enrollment.

(8) If a variance approved in accordance with paragraph (7) of this subsection expires, DADS may approve a subsequent variance if:

(A) changes to the individual's job duties require individualized supports and training beyond that expected as a normal part of the business setting in order for the individual to sustain current employment; and

(B) the program provider submits a written request for a variance to DADS.

(9) Supported employment is reimbursed on an hourly unit basis.

(f) The behavioral support service component provides specialized interventions that assist an individual to increase adaptive behaviors to replace or modify maladaptive or socially unacceptable behaviors that prevent or interfere with the individual's inclusion in home and family life or community life. The component is reimbursed on an hourly unit basis and includes:

(1) assessment and analysis of assessment findings of the behavior(s) to be targeted necessary to design an appropriate behavioral support plan;

(2) development of an individualized behavioral support plan consistent with the outcomes identified in the individual's PDP;

(3) training of and consultation with the LAR, family members, or other support providers and, as appropriate, with the individual in the purpose/objectives, methods and documentation of the implementation of the behavioral support plan or revisions of the plan;

(4) monitoring and evaluation of the success of the behavioral support plan implementation; and

(5) modification, as necessary, of the behavioral support plan based on documented outcomes of the plan's implementation.

(g) The adaptive aids service component provides devices, controls, appliances, or supplies and the repair or maintenance of such aids, if not covered by warranty, as specified in the waiver application approved by CMS that enable an individual to increase mobility, ability to perform activities of daily living, or ability to perceive, control, or communicate with the environment in which the individual lives.

(1) Adaptive aids are provided to address specific needs identified in an individual's PDP and are limited to:

(A) lifts;

(B) mobility aids;

(C) positioning devices;

(D) control switches/pneumatic switches and devices;

(E) environmental control units;

(F) medically necessary supplies;

(G) communication aids;

(H) adapted/modified equipment for activities of daily living; and

(I) safety restraints and safety devices.

(2) Adaptive aids costing more than $2,000 but not more than $6,000 in an IPC year may be provided for an individual if DADS has approved an exception to the service category limit of the Professional and Technical Support Service Category in accordance with §9.559 of this subchapter (relating to Request to Increase Service Category Limits).

(3) The adaptive aids service component does not include items or supplies that are not of direct medical or remedial benefit to the individual or that are available to the individual through the Medicaid State Plan, through other governmental programs, or through private insurance.

(h) The minor home modifications service component provides physical adaptations to the individual's home that are necessary to ensure the health, welfare, and safety of the individual or to enable the individual to function with greater independence in the home and the repair or maintenance of such adaptations, if not covered by warranty.

(1) Minor home modifications as specified in the waiver application approved by CMS may be provided up to a lifetime limit of $7,500 per individual. Minor home modifications costing more than $2,000 but not more than $7,500 in an IPC year may be provided if DADS has approved an exception to the service category limit of the Professional and Technical Support Service Category in accordance with §9.559 of this subchapter. After the $7,500 lifetime limit has been reached, an individual is eligible for an additional $300 per IPC year for additional modifications or maintenance of home modifications.

(2) The minor home modifications service component does not include adaptations or improvements to the home that are of general utility, are not of direct medical or remedial benefit to the individual, or add to the total square footage of the home.

(3) Minor home modifications are limited to:

(A) purchase and repair of mobility/wheelchair ramps;

(B) modifications to bathroom facilities;

(C) modifications to kitchen facilities; and

(D) specialized accessibility and safety adaptations.

(i) The dental treatment service component may be provided up to a maximum of $1,000 per individual per IPC year for the following treatments:

(1) emergency dental treatment;

(2) preventive dental treatment;

(3) therapeutic dental treatment; and

(4) orthodontic dental treatment, excluding cosmetic orthodontia.

(j) The respite service component is provided for the planned or emergency short-term relief of the unpaid caregiver of an individual.

(1) The respite service component provides an individual with:

(A) assistance with activities of daily living and functional living tasks;

(B) assistance with planning and preparing meals;

(C) transportation or assistance in securing transportation;

(D) assistance with ambulation and mobility;

(E) assistance with medications and performance of tasks delegated by a registered nurse in accordance with state law;

(F) habilitation and support that facilitate:

(i) an individual's inclusion in community activities, use of natural supports and typical community services available to all people;

(ii) an individual's social interaction and participation in leisure activities; and

(iii) development of socially valued behaviors and daily living and independent living skills.

(2) Reimbursement for respite provided in a setting other than the individual's residence includes payment for room and board.

(3) Respite is provided on an hourly or daily unit basis.

(4) Respite may be provided in the individual's residence or, if certification principles stated in §9.578(o) of this subchapter (relating to Program Provider Certification Principles: Service Delivery) are met, in other locations.

(k) The specialized therapies service component provides assessment and treatment by licensed occupational therapists, physical therapists, speech and language pathologists, audiologists, and dietitians and includes training and consultation with an individual's LAR, family members or other support providers. Specialized therapies are reimbursed on an hourly unit basis.

(l) Financial management services are provided if the individual participates in CDS.

(m) Support consultation is provided at the request of the individual or LAR if the individual participates in CDS.