§9.559: Request to Increase Service Category Limits

(a) If the cost of either service category included on an IPC submitted to DADS exceeds the service category limits described in §9.554(g)(1) and (2) of this subchapter (relating to Description of the TxHmL Program) but the total annual cost of the IPC does not exceed the combined cost limit specified in Appendix C of the TxHmL Program waiver application approved by CMS, an individual's service coordinator must request from DADS an increase in the appropriate service category limit.

(1) The service coordinator must submit the request in writing.

(2) The written request must be accompanied by documentation meeting the requirements of §9.558(b) of this subchapter (relating to Individual Plan of Care (IPC)).

(b) DADS reviews the request and approves or denies it.

(c) DADS may approve the request if the increase is determined necessary to protect the individual's health and welfare or to prevent the individual's admission to institutional services.

(d) DADS denies a request for an increase to the Professional and Technical Support Service Category if the request, if granted, would result in:

(1) more than $6,000 per IPC year for adaptive aids;

(2) more than $7,500 per IPC year for minor home modifications;

(3) more than $300 per IPC year for additional minor home modifications or minor home modification maintenance if the lifetime limit has been reached; or

(4) more than $1,000 per IPC year for dental treatment.

(e) As part of its review of the request, DADS reviews the individual's IPC in accordance with §9.558(d) of this subchapter.

(f) If DADS denies a request to increase a service category limit, DADS:

(1) notifies the individual's service coordinator; and

(2) notifies the individual or LAR of the individual's right to request a fair hearing in accordance with §9.571 of this subchapter (relating to Fair Hearings).


Source Note: The provisions of this §9.559 adopted to be effective January 5, 2003, 27 TexReg 12254; amended to be effective March 11, 2004, 29 TexReg 2317; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; amended to be effective March 1, 2007, 32 TexReg 544; amended to be effective June 1, 2008, 33 TexReg 4340