|(a) In this section, the term "individual" means a person applying for or enrolled in the Community Based Alternatives (CBA) Program, unless the context clearly indicates otherwise. (b) A CBA provider must coordinate with an interdisciplinary team to develop an ISP that is based on assessments conducted in accordance with §48.6020 and §48.6022 of this subchapter (relating to Pre-Enrollment Health Assessment; and Community Based Alternatives Annual Reassessment) and that meets the criteria in subsection (d) of this section. (c) Before providing CBA Program services in accordance with the (ISP), the CBA provider must obtain approval from the Department of Aging and Disability Services (DADS). (d) To be approved by DADS, CBA Program services in the ISP must: (1) be necessary to protect the individual's health and welfare in the community; (2) supplement rather than replace the individual's natural supports and other non-CBA Program services and supports for which the individual may be eligible; (3) prevent the individual's admission to an institution; (4) be the most appropriate type and amount of services to meet the individual's needs; and (5) be cost effective. (e) If the ISP includes a service that has a limit described in §48.6084(a)(2)(A) - (G) of this subchapter (relating to Service Limits and Claim Limits), the HCSSA must provide information to the DADS case manager, in accordance with §48.6085(a) of this subchapter (relating to Exception to Service Limit), that exceeding the limit is necessary to meet the individual's needs. (f) To demonstrate that the CBA Program services on the ISP meet the requirements described in subsection (d) of this section, the CBA provider must submit to DADS the following: (1) an assessment of the individual supporting the CBA Program services recommended by the CBA provider; and (2) documentation that other sources for adaptive aids and medical supplies are unavailable. (g) DADS conducts utilization review of an ISP and supporting documentation at any time to determine if the CBA Program services specified in the ISP meet the requirements described in subsection (d) of this section. (1) The CBA provider must submit documentation supporting the ISP to DADS as requested by DADS. (2) If DADS determines that one or more of the CBA Program services specified in the ISP do not meet the requirements described in subsection (d) of this section, DADS denies or reduces the service, modifies the ISP, and sends written notification to the individual and CBA Program provider. (h) In addition to the utilization review conducted in accordance with subsection (g) of this section, DADS may conduct utilization reviews of CBA providers and CBA Program services based on utilization patterns and trends.
|Source Note: The provisions of this §48.6006 adopted to be effective September 1, 1993, 18 TexReg 5509; amended to be effective September 1, 2008, 33 TexReg 7287; amended to be effective December 1, 2011, 36 TexReg 8061